Affordable Medicine
Solutions
Program
Terms and Agreement,
and
Privacy Notice
Program Terms and Agreement: These Affordable Medicine
Solutions Manufacturer to Consumer Financial Assistance Program Terms and
Conditions (“Terms and Conditions”) form an agreement between Affordable
Medicine Solutions, LLC,
1790 E. River Road,
Suite 205
Tucson,
Arizona
(“AMS”) and You. AMS administers manufacturer to consumer financial assistance
programs (“AMS Program(s)”) providing consumers with point-of-sale financial
assistance to reduce your out-of-pocket cost on covered products.
To access the point of-sale financial assistance available from AMS
Program manufacturers, You agree that AMS may receive transaction data related
to purchases that may be eligible for AMS Program Manufacturer Financial
Assistance; and that You will be assigned a unique financial services
identification number to facilitate the transfer of available AMS Program
Manufacturer Financial Assistance to You and then to Your pharmacy to result in
Your point-of sale savings.
By accessing AMS program assistance, whether by presenting your account
information in person at a participating local pharmacy; or through
communications with a participating specialty, online or mail order pharmacy
You agree that these Program Terms and Conditions and Privacy Notices apply,
and that You have agreed to abide by the terms, conditions, and rules set forth
herein. If You have questions that are not addressed here, please call Customer
Service at 1-800-258-1038. Please review this document carefully and keep it
with Your records.
The financial services account number You are assigned identifies the account
used by AMS to (1) secure the manufacturer assistance available to You, and (2)
apply these funds to make a payment to Your pharmacy on Your behalf to reduce
Your out-of-pocket cost.
By presenting Your AMS Program identification card or financial services
account number to Your pharmacy, by signing the back of the AMS Program
identification card, and/or by otherwise accessing Manufacturer Financial
Assistance through the AMS Program, You acknowledge and agree that: (1) the
financial services account is a restricted use account not a consumer credit or
debit card account; (2) has no consumer credit or tax implications; (3) does
not earn interest; (4) has no associated fees that You are responsible for; (5)
has no direct consumer access (such as Automatic Teller Machine access aside
from access to information regarding AMS Program transaction activity); (6)
will not be used to accumulate savings, and (7) that the account is restricted
to use for AMS Program purposes only.
Enrollee Assistance Procedures: If You have questions, have lost
or misplaced Your AMS Program Card or Eligibility Information or if You need
more information about the AMS Programs or an AMS Program transaction,
telephone us at 1-800-258-1038, write to us at Customer Service, P.O. Box
64187, Tucson, AZ 85728, or send an e-mail to us at
CustomerService@Amedisol.com as soon as You can. When You contact us,
please provide the following information: 1. Your name and 16-digit account
number (printed on the face of Your card or in Your Eligibility notification).
2. If Your question relates to a specific AMS Program transaction, please
provide the date and location of the transaction, and other information to
identify the transaction.
3. Explain as clearly as possible the information or resolution You are
requesting.
If You provide this information orally, AMS may require that You repeat Your
question or request in writing within 10 business days. AMS will tell You the
results of our investigation within 10 business days after AMS hears from You
and will correct any error promptly. If AMS needs more time, however, AMS may
take up to 45 days to investigate Your complaint or question. If AMS decides
there is no error, AMS will send You a written explanation within three (3)
business days of such findings. You may ask for copies of the documents that
AMS used in the investigation.
In case of questions regarding AMS Program offers or covered products, contact
the AMS Program Customer Service toll free line at 1-800-258-1038.
Disclaimer Of Liability: AMS makes no representations, express or
implied, including the warranty of merchantability or fitness for a particular
purpose, with respect to any of the benefits, or related information provided
to You. Under no circumstances shall AMS be liable for any special, incidental,
or consequential damages.
Change In Terms: AMS or any AMS Program manufacturer may, at any
time, and subject to applicable law add, delete, or modify the terms,
conditions, rights, and responsibilities relating to the AMS Programs. You will
be notified of any changes in terms. However, if the change is made for
security purposes, AMS can implement such change without prior notice. AMS
reserves the right to add, delete, change, modify, or replace, from time to
time, and without prior notice, any product, benefit, vendor, or service
provider, as AMS deems necessary in its sole discretion.
Miscellaneous Provisions: The laws of the State of Arizona govern
this Agreement without giving effect to the choice of law provisions thereof.
In the event that any part of this Agreement is declared to be void or
unenforceable, such provisions shall be deemed to have been severed from this
Agreement. The remainder of this Agreement shall remain in full force and
effect, and shall be modified to any extent necessary to give such force and
effect to the remaining provisions. No delay or forbearance in the strict
observance or performance of any provision of this Agreement, nor any failure
to exercise a right or remedy hereunder, shall be construed as a waiver of such
performance, right, or remedy, as the case may be.
PRIVACY POLICIES
AMS is committed to provide products, services, and offers of value to You. AMS
may use information from our interactions with You and other customers, and
from other parties, to help Us achieve that goal. AMS believes that the basis
of each customer relationship is trust. In order to preserve that trust, AMS
pledges to respect and protect Your privacy by adhering to practices intended
to safeguard Your personal information and ensure it is handled in a safe,
secure, and responsible manner. AMS is equally committed to protecting Your
privacy online. Our privacy policy applies in its entirety to Your Internet and
PC transactions. AMS will also continue to adhere to the privacy policies and
practices described in this notice even after Your account is closed or becomes
inactive.
Your Rights: You have the following rights related to both Your
Financial data and Your Health Information. You have the right to request
specific restrictions on uses or disclosures of Your Health Information for AMS
Program administration as described in this Health Information Notice. AMS
intends to honor all reasonable requests for restrictions on uses or
disclosures, but AMS is not required to agree to any request for a restriction.
If You choose not to receive direct mail or telephone solicitations, of
if you would like to change your earlier elections, please write to AMS Program
Customer Service at P.O. Box 64187, Tucson, Arizona 85728-4187 and to make such
requests. Please include Your name, address, and 16-digit AMS Program Card
number.
Why AMS Collects Your Information:
AMS gathers and maintains information about You and Your account to (1)
administer the AMS Programs; (2) know who You are and thereby prevent
unauthorized access to Your information; (3) design and improve the products
AMS offers; (4) provide customer assistance; and (5) comply with laws and
regulations that govern the AMS Programs. AMS collects and utilizes two
different types of confidential information:
Financial
data generated within the AMS Programs, which allows AMS to obtain manufacturer
financial assistance on Your behalf and apply those funds, according to the
Manufacturer’s terms, to bring You savings.
Transaction
data related to Your Program purchase(s), which may include Health Information,
allowing AMS to determine the eligibility of those purchase for manufacturer
financial assistance.
AMS is required to obtain and use Your confidential information in accordance
with applicable laws. AMS restricts access to non-public personal information
about You to employees, contractors or affiliates who need to know that
information to complete transactions or to provide products and services to
You. AMS maintain physical, electronic, and procedural safeguards to protect
Your information.
Financial Data Privacy Policy
What Information AMS Collects: AMS collects financial data or
"non-public personal information" about You, such as information AMS receives
from You on applications or other forms and information about Your AMS Program
transactions.
What Information AMS Discloses: AMS may share information with its
affiliates (i.e., companies related to AMS by common control or ownership) that
provide services necessary to administer the AMS Programs, such as transaction
processing companies. AMS is also permitted under law to disclose non-public
personal information about You to affiliates and “non-affiliated third parties”
that assist AMS in administering Your account.AMS requires all affiliates and
companies to which AMS discloses non-public personal information about You to
maintain their confidentiality. In certain circumstances, in order to comply
with government requirements or court orders, AMS is required to disclose
information about You or Your transactions. AMS share only the information
required and will do this only when required by law, regulation, or court
order.
AMS Program Service Announcements: AMS will communicate with You to
provide information to You regarding the AMS Program, covered products,
participating retailers, or changes in services. AMS may include information
from participating manufacturers or about AMS program options or services that
You have not yet chosen to receive.
Additional Rights and Modifications: You may have other privacy
protections under state laws, and AMS will comply with applicable state laws
when AMS share information about You. AMS may amend this privacy notice at any
time, and AMS will inform You of changes as required by law.
Health Information Privacy Policy
THIS “HEALTH INFORMATION NOTICE” DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE OBTAINED, USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS HEALTH INFORMATION
NOTICE CAREFULLY.
General Use and Disclosure of Health Information: In administering the
Program, AMS may receive pharmacy claims data from pharmacies where You
purchase prescriptions (“Health Information”). AMS needs this information to
administer the point-of-sale financial assistance program for You. To best
safeguard the privacy of Your Health Information, AMS follows policies based on
the data privacy and security practices required of Covered Entities under the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). Upon
Your use of the AMS Program, AMS will use Your Health Information for the
following purposes:
§
Program
Financial Assistance: AMS
may use Your Health Information to obtain available manufacturer rebates to
provide You savings when You purchase medications at Your pharmacy.
§
Health Information. AMS may use Your
Health Information to provide You with prescription compliance reminders, or to
communicate with persons involved in Your health care decision-making, such as
your pharmacist.
§
Legal
Disclosures. AMS may use
or disclose Your Health Information for the following oversight or legal
purposes: upon the request of Public Health oversight agencies; upon the
request or subpoena of a law enforcement or governmental authority; for
qualified research purposes; to a coroner or medical examiner as required by
law; and where otherwise required by law. AMS privacy policies are based on
federal laws and regulations; however, if Your state laws are more stringent it
is AMS’s intention to structure its policies to comply with those laws.
Uses
And Disclosures You Authorize: In
addition to the uses and disclosures described above, AMS requests Your written
authorization for other uses and disclosures AMS believes may be of benefit to
You. Such uses may include sending You health and savings information regarding
the AMS Program, and the products and services of participating manufacturers.
You are not required to agree to such an authorization, and You may revoke a
written authorization at any time. For more information on the revocation of
authorizations, please contact AMS Program Customer Care toll-free at
1-800-258-1038 and a representative will assist You.
You
have the right to inspect and receive copies of certain Health Information
about You that is maintained by AMS; and You have the right to request that AMS
amend the Health Information AMS maintains about You if You believe the
information about You is wrong or incomplete, although AMS is not required to
agree to such requests.
You
have the right to receive an accounting of certain AMS disclosures of Your
Health Information occurring during the six years prior to Your request. You
have the right to receive an electronic copy of this Health Information Notice
via e-mail or a paper copy of this Health Information Notice at any time.
If
You have questions regarding this Health Information Notice, Your Privacy
Rights or if You would like to request a copy of this Health Information Notice
You may contact AMS Program Customer Care toll-free at 1-800-258-1038. If You
believe Your privacy rights have been violated by AMS and believe it is
appropriate to file a complaint with AMS, You may telephone Member Services; or
send Your written complaint or inquiry by mail or e-mail using the following
contact information:
Affordable
Medicine Solutions, LLC,
PO Box 64187, Tucson, Arizona 85728-4187,
Attention: Privacy Office, or by calling toll free at 1-800-258-1038,
Or by Internet - privacycoordinator@amedisol.com
If You want to
make a complaint to the Secretary of the U.S. Department of Health and Human
Services regarding Your privacy, AMS will provide You with that address
information upon Your request. AMS will not retaliate against You in any way,
for filing a complaint based on Your belief that Your privacy rights have been
violated. AMS is committed to
maintaining the privacy and security of Your Health Information in a manner
consistent with HIPAA and to providing You with this Health Information Notice
explaining AMS Program policies on the privacy and security of Health
Information. AMS reserves the right to change this Health Information Notice
and its policies and procedures related to the privacy of all Health
Information AMS maintains from time to time. Upon any material change in this
Health Information Notice or AMS privacy policies and procedures related to
Health Information, AMS will send You a revised Health Information Notice via
U.S. Mail or e-mail, if applicable, within sixty (60) days of the changes
taking effect and will also post the new Health Information Notice at www.amedisol.com.
AMS will comply with the most recent version of this Health Information Notice.
THIS
NOTICE IS EFFECTIVE AS OF MARCH 1, 2006