Tonmya Together^TM Savings Program – Terms and Conditions

See Prescribing Information for Tonmya at www.tonixpharma.com.

With the Tonmya Together^TM Savings Card, eligible commercially-insured patients may lower their out-of-pocket costs for their prescription. Eligible insured patients may pay as little as $0, and the card pays up to an annual maximum benefit, which is based on certain factors, including but not limited to insurance coverage, claim details, and/or participation in other insurance plan-sponsored programs. Once the cap is reached, you will be responsible for paying 100% of your total copay amount. Program benefit calculated on FDA-approved dosing. A valid Prescriber ID# is required on the prescription.

Patients with questions about the Tonmya Together^TM Savings Program should call 844-851-3390.

Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

Pharmacist instructions for insured patients: Submit the claim to the primary Third Party Payer first, then submit the balance due to Capital Rx as a Secondary Payer as a copay-only billing using a valid Other Coverage Code (e.g., 3, 8). The patient may pay as little as $0, and the card pays up to the maximum benefit.
Reimbursement will be received from Capital Rx.

Restrictions: This offer is valid in the United States and Puerto Rico. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, TRICARE, or other federal or state health programs (such as medical assistance programs). Cash Discount Cards and other non-insurance plans are not valid as primary under this offer. If the patient is eligible for drug benefits under any such program, the patient cannot use this offer.
Federal and state laws and other factors may prevent or otherwise restrict eligibility.
By using this offer, the patient certifies that he or she will comply with any terms of his or her health insurance contract requiring notification to his or her payer of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. Tonix Medicine reserves the right to rescind, revoke, or amend this offer.

TONMYA Eligibility Criteria / Terms and Conditions

By using Tonmya Together^TM Savings Program you confirm that you understand and agree to comply with the following Terms and Conditions:

• Must be 18 years of age or older to redeem this savings card.
• This savings card is only valid for eligible patients with private/commercial insurance and Not Covered Patients. “Not Covered Patients” are defined as those patients who have private/commercial insurance, but the drug is not covered on the plan’s formulary or has an NDC block, prior authorization, step edit, or other restriction that has not been met.
• This savings card is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including but not limited to Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.
• Reimbursement limitations apply. Patient is responsible for all additional costs and expenses after reimbursement limits are reached, including additional copayment and coinsurance amounts.
• Patients with high deductible or coinsurance health plans may pay more than $0. For questions, please call 1-844-851-3390.
• Savings may not be applied to any outstanding deductible or coinsurance a patient may have.
• This savings card shall be applied only toward the cost of an eligible prescription product and not toward ancillary services or treatment costs.
• This savings card is good for use only with the products identified herein. No other purchase is necessary.
• You agree not to seek reimbursement for all or any part of the benefit received through this copay card and are responsible for making any required reports of your use of this program to any insurer or other third party who pays any part of the prescription filled.
• This savings card is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private/commercial insurance plan or other private/commercial health or pharmacy benefit programs.
• This savings card is valid ONLY for qualifying patients residing in the 50 U.S. states or Puerto Rico with commercial insurance who have a valid prescription for an FDA-approved indication for the qualifying Tonix Medicines therapy. This savings card is not valid where prohibited, taxed, or otherwise restricted.
• You must present this savings card along with your prescription to participate in this program.
• This savings card cannot be redeemed at government-subsidized clinics.
• This savings card is not health insurance.
• The selling, purchasing, trading, or counterfeiting of this savings card is prohibited by law. Void if reproduced.
• This savings card is not valid with other savings offers. This savings card has no cash value. No cash back.
• This savings card is not transferable.
• Tonix Medicines reserves the right to rescind, revoke, terminate, or amend this savings card at any time without notice.
• When you use this savings card, you are certifying that you understand and agree to comply with the program rules, regulations, eligibility requirements, and Terms and Conditions.
• For questions, please call 1-844-851-3390.