The Galderma Patient Assistance Program ("Program"), owned and operated by Galderma Laboratories, L.P. ("Galderma," "we," "us" or "our") is provided to you ("you") under the following terms and conditions, including the amendments thereto and with any additional terms and conditions, rules, or polices that may be applicable to particular offerings made in connection with the Program (collectively, the "Terms and Conditions"). Your failure to follow the Program's rules, whether listed below or in supplemental notices posted at various points in the Program, may result in termination of your access to the Program. Your access to and use of the Program are subject to the terms and conditions of this agreement and all applicable laws and regulations, including the laws and regulations governing copyrights and trademarks. The Terms and Conditions of this agreement shall supersede all previous Program rules and/or terms and conditions. The following Terms and Conditions may be modified by Galderma from time to time, without advanced notice. Any such changes shall be reflected in an updated version of the Terms and Conditions posted on this site. BY ACCESSING THE PROGRAM, YOU ACCEPT, WITHOUT LIMITATION OR QUALIFICATION, ALL OF THE TERMS AND CONDITIONS IN THIS AGREEMENT.

I. Program Description

The Galderma Patient Assistance Program offers Aklief® (trifarotene) Cream, 0.005%, Epiduo® Forte (adapalene and benzoyl peroxide) gel 0.1%/2.5%, Epsolay® (benzoyl peroxide) Cream, 5%, Mirvaso® (brimonidine) gel, 0.33%, Oracea® (doxycycline) Capsules, 40 mg,  Twyneo® (tretinoin and benzoyl peroxide) Cream, 0.1%/3%, Soolantra® (ivermectin) Cream, 1%, and  Sculptra® (“Products”) to underinsured patients at a reduced or no cost based on household income and size. Products provided under the Program cannot be provided to cover previously administered treatments or to replace product. All products provided through the Program must be used and prescribed on-label. Galderma reserves the right to rescind, revoke or amend Program at any time. The Program may be changed from time to time at Galderma’s sole discretion without advanced notice. Any change to the Program (e.g., benefits, rules, and product availability, etc.) or these Terms and Conditions will be posted on this site.

II.  Program Details

Prescription Products - The Galderma Patient Assistance Program offers certain prescription medications at no cost to patients depending on household income and size. Patients enrolled in the Program are eligible to receive prescription medications for up to one year from the date of approval. Upon application approval and receipt of the prescription from the patient’s prescriber, they will receive a shipment from the Program’s specialty pharmacy with the first month’s supply. Subsequent refill shipments must be requested by the patient and will only be shipped in one-month supplies. A prescription for a 90-day supply will not be honored. A maximum of eleven refills will be allowed. Patients may re-enroll for up to one additional year.

Sculptra - The Galderma Patient Assistance Program offers Sculptra® to patients at a reduced cost or no cost depending on household income and size. Patients enrolled in the Program are eligible to receive up to twelve vials of product over an eighteen (18) month period. After the initial enrollment period, patients may reapply for a twelve (12) month period and receive one additional shipment with up to six (6) vials for maintenance treatments. Upon application approval and receipt of both the prescription and cost share payment from the patient (if applicable), the licensed injector will receive an automatic shipment of product from the Program’s specialty pharmacy. A minimum of two vials and a maximum of four vials are allowed in each shipment. Subsequent shipments must be requested by the patient or prescriber and will not be processed earlier than two weeks after the last shipment. 

III. Program Eligibility

The Program is open to legal residents of the United States of America who have completed an application and have had their healthcare provider complete an application and provide a prescription for the Product(s) to the designated specialty pharmacy.

Maximum annual gross income requirements to participate in the Program are shown in the below tables.

Maximum Annual Gross Income Requirements for Products, excluding Sculptra®

Household Size	48 Contiguous States*	Alaska	Hawaii
1	$25,760	$32,180	$29,640
2	$34,840	$43,540	$40,080
3	$43,920	$54,900	$50,520
4	$53,000	$66,260	$60,960
5	$62,080	$77,620	$71,400
6	$71,160	$88,980	$81,840
7	$80,240	$100,340	$92,280
8	$89,320	$111,700	$102,720
9	$98,400	$123,060	$113,160
10	$107,480	$134,420	$123,600
11	$116,560	$145,780	$134,040
12	$125,640	$157,140	$144,480
13	$134,720	$168,500	$154,920
14	$143,800	$179,860	$165,360

*District of Columbia, Puerto Rico, and U.S. Virgin Islands

Maximum Annual Gross Income Requirements for Sculptra®

Household Size	48 Contiguous States*	Alaska	Hawaii
1	$57,960	$72,405	$66,690
2	$78,390	$97,965	$90,180
3	$98,820	$123,525	$113,670
4	$119,250	$149,085	$137,160
5	$139,680	$174,645	$160,650
6	$160,110	$200,205	$184,140
7	$180,540	$225,765	$207,630
8	$200,970	$251,325	$231,120
9	$221,400	$276,885	$254,610
10	$241,830	$302,445	$278,100
11	$262,260	$328,005	$301,590
12	$282,690	$353,565	$325,080
13	$303,120	$379,125	$348,570
14	$323,550	$404,685	$372,060

*District of Columbia, Puerto Rico, and U.S. Virgin Islands

You may be asked to submit documentation (e.g., federal tax returns; IRS forms, such as W-2, 1099, 4506T; Social Security statement/checks/benefit letter; pension or disability benefit statement/letter; unemployment compensation statement; pay stubs) to validate levels of income.

Patients residing in a hospital, nursing home, correctional facility or court appointed program or facility are not eligible. Patients with government health insurance or private health insurance with a medical or prescription benefit that covers the Products are also not eligible. Proof of denied coverage is required when you are insured. Patients who participate in a State Pharmacy Assistance Program with a benefit that covers the Products are not eligible. Galderma in its sole discretion can determine your participation in the Patient Assistance Program.

Approved patients are eligible to receive assistance for up to 12 months for eligible prescription products and 18 months for Sculptra® from the date of approval. Continued income and insurance eligibility will be reconfirmed annually. If you have a change in insurance status or income, you may be deemed no longer eligible for the program. If you were previously denied enrollment in the Patient Assistance Program, you may reapply if you experience a change in circumstance impacting your eligibility. The program requires that you re-enroll every year by completing a Program application form.

IV. Enrollment

To enroll you must submit an application through the Galderma Patient Assistance Program. To complete enrollment, your healthcare provider (prescribing physician or licensed injector) will be asked to submit supportive information that includes a prescription for the product. All applications are reviewed based on program eligibility guidelines. In consideration of your use of the Program, you agree to provide true, accurate, current, and complete information about yourself as prompted by the online registration form and to maintain and promptly update your personal data to keep it true, accurate, current, and complete. You will be required to re-attest to eligibility requirements after the end of each calendar year (12/31/YY), regardless of the your enrollment term (start and end date).

If you provide any information that is not true, inaccurate, not current, or incomplete; or if we have reasonable grounds to suspect that such information is not true, inaccurate, not current, or incomplete, we have the right to suspend or terminate your account and to refuse any and all current or future use of the Program (or any portion thereof) by you. Only one account per person. If you attempt to sign up for more than one account, we may terminate your account and your eligibility in the Program will be forfeited.

V. Medical Advice

NO INFORMATION CONTAINED ON THIS SITE OR IN ANY EMAIL OR OTHER CORRESPONDENCE SENT TO YOU BY GALDERMA IS PROVIDED WITH THE INTENTION TO GIVE MEDICAL ADVICE OR INSTRUCTIONS ON THE APPROPRIATE USE OF OUR PRODUCTS AND TREATMENTS. WE CANNOT ANSWER UNSOLICITED E-MAILS REQUESTING PERSONAL MEDICAL ADVICE; YOU SHOULD ALWAYS CONSULT A HEALTH CARE PROFESSIONAL.

VI. Reservation of Rights

The Program is offered at Galderma’s discretion, and Galderma has the right to modify or discontinue, temporarily or permanently, the Program, in whole or in part, for any reason, at its sole discretion. You agree that Galderma will not be liable to you or any third party for any modification or discontinuance of the Program or any benefit offered, in whole or in part.

VII. Use of Your Personal Information

BY PARTICIPATING IN THE PROGRAM, YOU:

A. AGREE WE MAY COLLECT THE FOLLOWING PERSONAL INFORMATION FOR THE SOLE PURPOSE OF ADMINISTERING THE PROGRAM:

• CONTACT DETAILS
• HEALTH INSURANCE COVERAGE
• HOUSEHOLD ANNUAL GROSE INCOME AND SIZE
• HEALTHCARE PROVIDER CONTACT INFORMATION

B. AUTHORIZE YOUR HEALTHCARE SPECIALIST TO ENTER YOUR PERSONAL INFORMATION INTO PROGRAM WEBSITES ON YOUR BEHALF.

VIII. Fraud

Fraud or abuse relating to the application and information given to enroll in the Program may result in termination of your enrollment.

You and your prescriber may not bill, charge, seek credit for or otherwise submit any claim for reimbursement to any third-party payer for product provided through the Galderma Patient Assistance Program. No product provided through the Program may be sold, traded, or returned for credit.

IX. Violation of the Terms

You understand and agree that in our sole discretion, and without prior notice, we may terminate your access to the Program if we determine that you have violated our Terms and Conditions.

X. Proprietary Rights

You should assume that all contents of this site are copyrighted unless otherwise noted and may not be used except as provided herein and without our express written permission. Except as expressly provided herein, nothing contained herein shall be construed as conferring any license or right under any Galderma. All product names, logos, and service marks displayed on this site that are identified by ® or ™ or appearing in type form different from that of the surrounding text (collectively, the "Trademarks") are registered or unregistered trademarks owned by or licensed to Galderma, or its affiliates, unless otherwise identified as being owned by another entity. Nothing contained herein shall be construed as conferring by implication, estoppel, or otherwise any license or right, either express or implied, under any patent or Trademark of Galderma, its affiliates, or any third party. No use of any Trademark may be made without prior written authorization.