ELIGIBLE PATIENTS MUST:

• Have commercial insurance that covers DOPTELET
• Not be covered by a state or federal healthcare program such as Medicare, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD), or TRICARE
• Be 18 years of age or older
• Be a resident in the United States or a US Territory
• Be prescribed DOPTELET for an FDA-approved use

HOW TO ENROLL?

For assistance visit Dova1Source.com or call 1-833-368-2663.

TERMS AND CONDITIONS

• Patient pays $0 per prescription. Maximum benefit of up to $5,000 per DOPTELET prescription. Patient is responsible for any remaining out-of-pocket costs that exceed $5,000 per prescription. Copay Program has an annual cap of $15,000.
• Patient has on-label prescription.
• The Commercial Copay Program is limited to one person
• The Commercial Copay Saving Program is void where prohibited by law, taxes, or restricted
• This offer is non-transferable, no substitutions are permissible, and this offer cannot be combined with any other rebate/ coupon, free trial, or similar offer for the specified prescription.
• Dova Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice.
• The Commercial Copay Program for DOPTELET is not insurance and is not intended to substitute for insurance.
• Patients, pharmacists, and healthcare providers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this Commercial Copay Program. Patients must not seek reimbursement from any health savings, flexible spending, or other healthcare reimbursement accounts for the amount of assistance received from the Commercial Copay Program
• Certain information pertaining to your use of the Copay Program will be shared with Dova Pharmaceutics, the sponsor of the Copay Program. The information disclosed will include the date the prescription is filled, the number of pills or product dispensed by the pharmacists, and the amount of your co-pay that will be paid for by using this Copay Program. For more information, please see the Dova Pharmaceuticals Privacy Policy at www.dova.com.
• Acceptance in this Program is not conditioned on any past, present, or future purchase, including additional doses.
• Enrollment for the Copay Program is valid through the calendar year
• These Terms and Conditions are valid for a patient's DOPTELET prescription administered between January 1, 2019 and December 31, 2019