TERMS AND CONDITIONS

• Eligible commercially insured patients (other than High Deductible Patients) who have coverage for XHANCE (“Covered Patients”) and fill their prescription through the XHANCE Preferred Pharmacy Network (“PPN”) will receive their initial prescription of XHANCE (up to a 90-day supply) for an out-of-pocket cost of $0.
• Covered Patients who fill their prescription through the XHANCE PPN, and are validly enrolled in a qualifying refill program through certain participating XHANCE PPN pharmacies, will receive their refills of XHANCE (up to a 90-day supply) for an out-of-pocket cost of $0.
• Covered Patients who fill their prescription through the XHANCE PPN, and do not participate in a qualifying refill program, will receive their refills of XHANCE (up to a 90-day supply) for an out-of-pocket cost of $25 or less.
• Eligible commercially insured patients who have coverage for XHANCE where they are responsible for an out-of-pocket cost of more than 90% of the Wholesale Acquisition Cost (“High Deductible Patients”) and fill their prescription through certain participating XHANCE PPN pharmacies will receive their initial or refill prescription of XHANCE (up to 2 units) for an out-of-pocket cost of $25. For clarity, High Deductible Patients are not eligible for the offers specified above.

• Eligible commercially insured patients who do not have coverage for XHANCE (“Not Covered Patients”) due to a requirement from their insurance provider for a prior authorization, and fill their prescription through the XHANCE PPN, will receive their initial prescription of XHANCE for an out-of-pocket cost of $0 (up to 2 units).
• All other Not Covered Patients who fill their prescription through the XHANCE PPN will receive their initial prescription of XHANCE for an out-of-pocket cost of $25 per unit (up to 2 units).
• All Not Covered Patients who fill their prescription through the XHANCE PPN will receive their refills of XHANCE for an out-of-pocket cost of $50 per unit (up to 2 units).

• Offers to purchase XHANCE may be available to eligible cash-paying patients (patients acquiring XHANCE not through insurance) through certain participating XHANCE PPN pharmacies.

• Covered Patients who fill their prescription through a retail pharmacy utilizing the XHANCE copay card will receive their initial prescription of XHANCE (up to a 90-day supply) for an out-of-pocket cost of $0, and will receive their refills of XHANCE (up to a 90-day supply) for an out-of-pocket cost of $25 or less.
• High Deductible Patients who fill their prescription through a retail pharmacy utilizing the XHANCE copay card will receive their initial or refill prescription of XHANCE (up to 2 units) for an out-of-pocket cost of $25.

• All copay support offers are subject to an annual maximum benefit of $13,917 per patient.
• These offers are valid for patients 18 years of age or older and are good for use only with a valid prescription for XHANCE^®.
• Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for these offers. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare. If you are enrolled in a state or federally funded prescription insurance program, you may not use these offers even if you elect to be processed as an uninsured (cash-paying) patient.
• Copay support paid by these programs to reduce a patient’s out-of-pocket costs may not be submitted as a claim for payment to any third-party payer, pharmaceutical patient assistance foundation, or account such as a Flexible Spending Account (FSA), a Health Savings Account (HSA), or a Health Reimbursement Account (HRA), and may be required to be reported by the patient to its insurance provider.
• These offers are not insurance and are restricted to residents of the United States, including Puerto Rico, at participating pharmacies. Void where prohibited by law, taxed, or restricted.
• These offers are not valid for prescriptions costs paid or reimbursed entirely by health benefit programs. Cash discount cards are not commercial payers and are not eligible to be used in conjunction with this program.
• These offers and the XHANCE copay card have no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer.
• Optinose reserves the right to rescind, revoke, or amend these offers and terms and conditions of use at any time without notice.
• By accepting any of these offers or using the XHANCE copay card, patient authorizes the transfer of his XHANCE prescription to any pharmacy within the XHANCE PPN.

Patients may call 1-833-4XHANCE to be connected to a pharmacy participating in the XHANCE Preferred Pharmacy Network and for other offers that may be available.

Last updated: September 2022.