TERMS AND CONDITIONS

xhance preferred pharmacy network

COMMERCIALLY INSURED PATIENTS WITH COVERAGE FOR XHANCE

  • Eligible commercially insured 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 a participating PPN pharmacy, 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.
  • Copay support offers for Covered Patients within the XHANCE PPN are subject to a maximum patient benefit of $1,130 per fill.

COMMERCIALLY INSURED PATIENTS WITHOUT COVERAGE FOR XHANCE

  • 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).

RETAIL PHARMACIES

COMMERCIALLY INSURED PATIENTS WITH COVERAGE FOR XHANCE

  • 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.
  • Copay support offers for Covered Patients within retail pharmacies are subject to a maximum patient benefit as follows:
    • Initial fill ($490 for 1 unit; $980 for 2-6 units)
    • Refills ($465 for 1 unit; $955 for 2-6 units)

GENERAL TERMS AND CONDITIONS

  • All copay support offers are subject to an annual maximum benefit of $13,000 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 this offer. 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 this offer 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).
  • 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.

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: January 2021.

Important Safety Information
  • Do not use XHANCE if you are allergic to fluticasone propionate or any of the ingredients in XHANCE. Get emergency medical care if you get any of these signs of a serious allergic reaction: rash, hives, swelling of your face, mouth, and tongue, breathing problems, or low blood pressure.
  • Tell your healthcare provider about all your medical conditions and medications that you take. It is especially important to mention if you take antifungal or anti-HIV medicines as they may interact with XHANCE.
  • XHANCE can cause nasal problems such as nosebleeds, crusting, sores, hole in the septum, and slow wound healing.
  • XHANCE can cause eye problems including glaucoma and cataracts. You should have regular eye exams when using XHANCE.
  • XHANCE may increase the risk of infections and can make certain infections worse. Avoid contact with people who have a contagious disease such as chickenpox or measles while using XHANCE.
  • XHANCE can cause reduced production of steroid hormones by your adrenal gland, resulting in tiredness, weakness, nausea and vomiting, and low blood pressure.
  • XHANCE can weaken bones (osteoporosis).
  • Other side effects may include redness, pain, or swelling of the nose or throat, thrush (fungal infection of the nose and throat), nasal congestion, sinus infection and headache.

These are not all the side effects of XHANCE. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

Indication

XHANCE is a prescription medicine used to treat nasal polyps in adults.

Please see Patient Information, full Prescribing Information, and Instructions for Use.