TERMS AND CONDITIONS
This Agreement (the “Agreement”) governs your (“Patient”) and the pharmacy’s (“Pharmacy,” “You” or
“Your”) participation in the below-referenced program, the MyVTAMA Program (“Program”). The Program is
offered by Dermavant Sciences, Inc., having its operations at 2102 E. State Highway 114, Suite 217,
Southlake, Texas 76092 (“Dermavant”). Throughout this Agreement, Dermavant and Pharmacy may be referred
to individually as a “Party” or collectively as “Parties.”
WHEREAS, Dermavant offers the Program to Patients and Pharmacies.
NOW, THEREFORE, for good and valuable consideration, the sufficiency of which is hereby acknowledged,
the Patient and Parties agree as follows:
The Program is brought to you by Dermavant. The Program is available for commercially insured
patients. Patients who are enrolled in a government-run or government-sponsored healthcare
plan with a pharmacy benefit are not eligible to use the MyVTAMA Patient Savings Card (“Card”). This
Card provides savings on out-of-pocket expenses for up to a 90-day supply of included Dermavant
products, as described below. Maximum day supply limit may vary. If you have valid prescriptions for
more than one Dermavant product, the copay expense and savings apply to each product. You may use this
Card once every 25 days, depending on when you last received a 30-day supply of each Dermavant product.
Use of this Card does not obligate you to use or to continue using any Dermavant product. You may use
this Card at any participating pharmacy located in the United States.
This Card may not be combined with any savings, discount, free trial, or other similar offer for the
same prescription. This Card is not transferable and is void if reproduced. This Card is not health
insurance. Limit one (1) Card per patient per use. This Card has no cash value and will not be accepted
outside of participating pharmacies in the United States. Please visit Dermavant’s website for our
Use of this Card is subject to applicable state and federal law, and is void where prohibited by law,
rule or regulation. In the event a lower cost generic drug that the FDA had designated as a
therapeutically equivalent product is available for one of the Dermavant products covered by this Card,
or if the active ingredient of a Dermavant product is available at a lower cost without a prescription,
this offer will become void in California with respect to the Dermavant product.
Dermavant reserves the right to rescind, revoke, or amend these terms and conditions at any time,
becoming effective upon publication at
www.VTAMA.com/terms-conditions, and to deny payment
for noncompliance with these terms and conditions in its sole discretion.
Terms and Conditions
Eligible commercially insured patients are responsible for paying
out-of-pocket expenses and any amount that exceeds the Dermavant payment for each
prescription, as follows:
Use of this Card may be subject to limitations imposed by state or federal law, or by your health
insurer. This Card is not valid where prohibited by law or by your health insurer.
The MyVTAMA program is only available for commercially insured patients. Patients who are
enrolled in Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE, or any other government-run or
government-sponsored healthcare program with a pharmacy benefit (“Government Beneficiary”) are not
eligible to use the Card.
You must present this card to the pharmacist along with your prescription each time you fill your
prescription to participate in the Program. If you have any questions regarding your eligibility or
benefits or if you wish to discontinue your participation, call the Dermavant Savings Program customer
support at 347-532-5250 (9:00 AM-7:00 PM EST, Monday-Sunday).
When you use this Card, you are certifying that you understand the Program rules, regulations, and
these terms and conditions which are also set forth at
www.VTAMA.com/terms-conditions, and that you will
comply with them. You are not eligible if you are a Government Beneficiary. No purchase is necessary and
there are no membership fees. You may not use this Card if prohibited by your insurer. You are
responsible for any reporting for the use of this Card as required by your insurer.
By using this Card, you acknowledge that you currently meet the following eligibility criteria:
You have a valid prescription for the Dermavant product your copay and the savings apply to;
You have no insurance or are subject to a private insurance copay requirement for your
You are not a Government Beneficiary;
You are at least 18 years old;
You reside in the United States.
When you accept/use this Card, you are certifying that you have not submitted and will not submit a
claim for reimbursement under Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE or any other
government-run or government-sponsored healthcare program with a pharmacy benefit for this prescription
and that you agree to and understand the Program rules, regulations, and these terms and conditions
which are also set forth at
www.VTAMA.com/terms-conditions, and that you will
comply with them. By accepting/using this Card, you acknowledge and agree to/that:
Submit transaction to Pharmacy Data Management Inc. (PDMI), using Bin #610020. Pharmacy participation,
payments, and reimbursement are subject to terms and conditions negotiated between PDMI and the
Pharmacy. For questions regarding PDMI processing, setup, claims transmission, patient eligibility, or
other issues, please call 1-800-800-7364.
If commercial prescription insurance exists, you shall run the commercial prescription insurance as
primary insurance, input Card information as secondary coverage, and transmit using the COB segment of
the NCPDP transaction. Applicable discounts will be displayed in the transaction response;
If commercial prescription insurance does not exist, only then may you run the Card for uninsured
Acceptance of this Card and your submission of claims for the Program are subject to our Card
administrator, Apollo. Apollo program Terms and Conditions posted at
Patient is not eligible if patient is a Government Beneficiary or where prohibited by law; and
If you are filling a prescription in the state of California, in the event a lower generic drug
that the FDA has designated as a therapeutically equivalent product becomes available for one of the
Dermavant products covered by this Card, or if the active ingredient of a Dermavant product is
available at a lower cost without a prescription, this offer is void with respect to that Dermavant
product and you agree not to apply this Card to any discount or savings to such patient under the
Program for such Dermavant product.
PHARMACY AGREES THAT ITS PARTICIPATION IN THE PROGRAM IS STRICTLY VOLUNTARY AND AT PHARMACY’S OWN
RISK. PHARMACY UNDERSTANDS AND AGREES THAT DERMVANT, ITS ADMINISTRATOR OF THE CARD, AND PATIENTS
DISCLAIM ANY AND ALL WARRANTIES, REPRESENTATIONS AND CONDITIONS, WHETHER EXPRESS OR IMPLIED, WITH
RESPECT TO THE PROGRAM AND PHARMACY’S PARTICIPATION IN IT. PHARMACY FURTHER UNDERSTANDS AND AGREES THAT,
EXCEPT FOR THE AMOUNT DUE TO PHARMACY, AS DEFINED HEREIN, PHARMACY IS NOT ENTITLED TO PAYMENT OR
COMPENSATION OF ANY KIND.
Pharmacy will make no representations or warranties of any kind on behalf of Dermavant, its
Administrator of the Card, their respective products or Program, or patients. Dermavant will not be
liable for any claim, injury, demand or judgment based on tort or other grounds (including, without
limitation, warranty of merchantability) arising out of the sale or dispensing of any prescription drug
provided by Pharmacy to any person arising out of Pharmacy’s negligence, violation of law, or willful
misconduct; and Pharmacy agrees to defend Dermavant and indemnify and hold Dermavant harmless from and
against any and all such claims, injuries, demands and judgments, including, without limitation, payment
of all costs and attorneys’ fees.
Limitation of Liability:
PHARMACY UNDERSTANDS AND AGREES THAT IN NO EVENT WILL DERMAVANT, ITS ADMINISTRATOR OF THE CARD,
PATIENTS, OR THEIR RESPECTIVE OFFICERS, DIRECTORS, SUBSIDIARIES, AFFILIATES, OR SUPPLIERS BE LIABLE FOR
DAMAGES OF ANY KIND, WHETHER DIRECT, INDIRECT, CONSEQUENTIAL, INCIDENTAL, PUNITIVE, OR OTHERWISE,
HOWEVER CAUSED AND REGARDLESS OF THE THEORY OF LIABILITY, ARISING OUT OF THESE TERMS AND CONDITIONS OR
PHARMACY’S PARTICIPATION IN THE PROGRAM, EVEN IF DERMAVANT HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH
Audit and Review Rights:
Dermavant or its designee will have the right upon prior written notice, and during normal business
hours, during Pharmacy’s participation in the Program and for a period of two (2) years thereafter,
subject to applicable law (including those governing confidentiality), to audit or review Pharmacy’s
records as they pertain to Pharmacy’s compliance with this Agreement. In the event that any such audit
or review reveals any erroneous amounts paid to Pharmacy, Pharmacy agrees to pay Dermavant any such
amounts within fifteen (15) calendar days of written demand by Dermavant. Pharmacy shall provide access
to records or requested records within a reasonable period of time not to exceed fifteen (15) business
days, unless a longer period of time is agreed to by the Parties in writing. The rights provided in this
Section will be cumulative and in addition to any other rights or remedies that may be available to
Acceptance and participation in the Program and/or the use of this Card constitutes an agreement with
Dermavant in Texas and the transactions underlying the participation in the Program and use of this Card
is performable for all purposes in Texas. By participating in the Program and using this Card, you agree
that the transaction has a reasonable relationship to the State of Texas in that, among other things,
this Card and the Program originated from the State of Texas and Dermavant will perform a substantial
part of its respective obligations in the State of Texas. It is agreed that the exclusive venue for any
dispute arising out of participation in the Program and/or this Card is a state or federal court of
competent jurisdiction in Tarrant County, Texas. By participating in Program and using this Card, you
irrevocably and unconditionally submit to the exclusive jurisdiction of a state or federal court in
Tarrant County, Texas.
You consent to the Program and use of this Card being governed by and interpreted in accordance with
the substantive laws of the State of Texas without regard to its conflict of law principles.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit
www.FDA.gov/MEDWatch, or call 1-800-FDA-1088.