SPRITAM^® Important Safety Information

SPRITAM SERVE Savings Program

In order to participate in the SPRITAM SERVE Savings Program (“Program”), you must have a valid prescription for SPRITAM® (levetiracetam) Tablets for Oral Suspension and meet the eligibility requirements set forth herein. By using this Program, the user certifies that he or she (i) is over the age of 18, (ii) is the patient or the patient’s caregiver and has the patient’s consent to use this offer, and (iii) meets the eligibility criteria and will comply with the terms and conditions of the Program set forth below.  Patients with questions about the Program should call (844) 777-4826.  The Program consists of three separate offerings, each of which has certain unique eligibility requirements and limitations, as further described below.  Each patient is limited to one Program offering and none of the Program offerings may be combined.

A. Retail Pharmacy Electronic Voucher (e-voucher) Program

The SPRITAM SERVE E-voucher can be applied to eligible claims at retail pharmacies who participate in Relay Health’s e-voucher programs. The e-voucher will be automatically applied to eligible prescriptions at the time of adjudication by Relay Health through the participating pharmacy. The E-voucher is available to:

1. Commercially insured patients whose plan covers SPRITAM with a co-pay that exceeds $10 for a 30-day supply. For such patients, Prasco, LLC buys down a one-month, 60-tablet supply to a patient co-pay as low as $10. The maximum SPRITAM SERVE E-voucher amount for 60 tablets is $390 per 30-day supply for commercially covered claims.
2. Commercially insured patients whose plan does not cover SPRITAM. For such patients, Prasco, LLC buys down a one-month, 60-tablet supply to as low as $75. The SPRITAM SERVE E-voucher offers a maximum benefit of $2,000 per patient per calendar year for uncovered patients.

The patient is responsible for any costs once these limits are reached.

The SPRITAM SERVE E-voucher is not available to uninsured patients.

B. Spritam Serve Savings Coupon (“Coupon”)

The SPRITAM SERVE Coupon can be applied to eligible claims . Patients must present the Coupon card to the pharmacist along with a valid SPRITAM prescription.  The Coupon is available to:

1. Commercially insured patients whose plan covers SPRITAM with a co-pay that exceeds $10 for a 30-day supply. For such patients, Prasco, LLC buys down a one-month, 60 tablet supply to a patient co-pay as low as $10. The Coupon is limited to 12 fills per calendar year for commercially covered claims. The SPRITAM SERVE Coupon offers a maximum benefit of $5,000 per patient per calendar year for insured patients with coverage for SPRITAM.
2. Commercially insured patients whose plan does not cover SPRITAM or uninsured patients. For such patients, Prasco, LLC buys down a one-month 60-tablet supply to a patient co-pay as low as $10. The SPRITAM SERVE Coupon offers a maximum benefit of $2,500 per patient per calendar year for uncovered or uninsured patients.

The patient is responsible for any costs once these limits are reached.

C. Blink Health Specialty Pharmacy Savings Program

Prasco, LLC has partnered with Blink Health Pharmacy, LLC (“Blink Health”) to offer savings to commercially insured patients.  SPRITAM prescriptions eligible for The SPRITAM SERVE Blink Health must be filled and dispensed by Blink Health or one of its participating partner pharmacies.  The SPRITAM SERVE Blink Health offering is available to:

1. Commercially insured patients whose plan covers SPRITAM with a co-pay that exceeds $10 for a 30-day supply. For such patients, Prasco, LLC buys down a one-month, 60 tablet supply to a patient co-pay as low as $10.
2. Commercially insured patients whose plan does not cover SPRITAM or uninsured patients. For such patients, Prasco, LLC buys down a one-month 60-tablet supply to a patient co-pay as low as $75.

The SPRITAM SERVE Blink Health offerings offers a maximum benefit of $5,000 per patient per calendar year.  The patient is responsible for any costs once these limits are reached.

General Spritam Serve Savings Program Terms and Conditions

The following terms and conditions are applicable to each offering under the Program.

Patient savings may vary based on insurance coverage and tablet amount.  Prescriptions must be written to a pharmacy that has elected to participate in the applicable Program offering.  Maximum coverage limits and exclusions apply and vary by savings vehicle as described above in sections A, B and C. The Program is good for a maximum of 365 days of therapy (limited to 60 tablets per month) over 12 months and will renew for an additional 12-months after the conclusion of each 12-month period.   The patient is responsible for any costs once the applicable limit is reached during the applicable period.  The Program is subject to change at any time.

The Program is not valid (i) for use by patients who are covered by any federal or state funded health care program (including, but not limited to, Medicare, Medicaid, TRICARE, VA or DoD), or (ii) where the patient’s insurance plan reimburses for the entire cost of the drug. The value of this Program is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations. The Program is not valid where prohibited by law. The patient may not seek reimbursement for the value received from this offer from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. The patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the savings Program. Valid only in the United States where copay savings programs are allowable by law. This offer is not health insurance. Offer may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required.  By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions of the Program.

Prasco, LLC reserves the right to rescind, revoke or amend this program without notice at any time.