Informed Consent

Patient Informed Consent to Pharmacy Services

Mark Cuban Cost Plus Drug Company, PBC partners with HealthDyne Pharmacy Inc.’s network of affiliated pharmacies for quality pharmacy services, but you always have the right to have your prescription filled by any pharmacy of your choice. By choosing HealthDyne Pharmacy Inc.’s affiliated pharmacy network, you agree to fulfillment of the prescription as follows:

Pharmacy Network.

You acknowledge that in some cases, when allowed by law, one or more pharmacies may be involved in the processing and dispensing of your prescription. HealthDyne Pharmacy Inc.’s affiliate pharmacy may need to transfer or forward your prescription to another pharmacy. If that is necessary, based on the state in which you live, by continuing with this transaction, you authorize both HealthDyne Pharmacy Inc.’s affiliate pharmacy to transfer the prescription to another pharmacy. You may cancel your prescription order at any time or request to transfer your prescription to another pharmacy.

Customer Support.

You acknowledge that use of Mark Cuban Cost Plus Drug Company’s customer support may involve support services from Mark Cuban Cost Plus Drug Company and/or one of its third-party vendors, including HealthDyne Pharmacy Inc.’s affiliate pharmacy network. Those support services may involve electronic communication of your personal medical information to Mark Cuban Cost Plus Drug Company, HealthDyne Pharmacy Inc.’s affiliate pharmacy network, which may be located outside of the state in which you reside, and that the electronic systems, public networks, or security protocols or safeguards used in the Services could fail, causing a breach of privacy of your medical or other information. You understand that it is your duty to provide your truthful, accurate, and complete information, including all relevant information regarding care that you may have received or may be receiving from other healthcare providers.

Authorization to Fill Your Prescription Order and Bill Your Insurance Company.

Anytime you present your prescription(s) and your prescription insurance billing information, you are authorizing Mark Cuban Cost Plus Drug Company, HealthDyne Pharmacy Inc. or one of its affiliated pharmacies to bill the fee for your prescription to your insurance company or its agents, and you agree to pay any out-of-pocket copayment amount assigned by your insurance company.

Payment Policies and Procedures.

Payment in full for services, including any copayments assigned by your insurance company, are due at the time services are performed or medications are picked up or delivered. As the patient/guarantor, you are financially responsible for any fees and costs associated with any services or products you receive from HealthDyne Pharmacy Inc.’s affiliate pharmacy. Co-payments will be collected at the time of service either directly by the Inc. affiliate pharmacy or by Mark Cuban Cost Plus Drug Company on behalf of the pharmacy.

As the patient/guarantor, it is your responsibility to know your insurance benefits and to provide the pharmacy with accurate and current insurance information.

If you are a patient with a secondary insurance, a coupon, or other discount permitted by law and your insurance company, it is your responsibility to provide both your insurance identification card, secondary insurance identification card, coupon, or other authorized coupon or discount card. If the pharmacy does not have the proper information for a secondary insurance, including coupons, the secondary insurance will not be billed. If your secondary insurance, coupon, or other discount is legal and permitted by your primary insurance, the pharmacy will collect payment from that secondary payor.

HealthDyne Pharmacy Inc. or one of their affiliates will bill your insurance as applicable, however, you are ultimately liable for any fees and costs not covered or paid by your insurance. Questions about non-payment should be directed to your insurance company. In the event that your medication is not covered by your insurance company for any reason including, but not limited to: drug not covered, non-participating pharmacy, out-of-network pharmacy, prior authorization required, step therapy required, or other rejection message the pharmacy staff, or Mark Cuban Cost Plus Drug Company on behalf of the pharmacy staff, will review this information with you including information about how to obtain prior authorization (if applicable). You have the option of paying the pharmacy cash at our Usual & Customary rate if your medication or order is not covered by your insurance.

Patient Responsibility.

I understand and agree that I am financially responsible for all charges for any and all services rendered.

I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.

I understand and agree that it is my responsibility to know if my insurance has any deductible, co- payment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.

I agree to inform the pharmacy of any changes in my insurance coverage. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full.

By agreeing to these terms of service, I am attesting that the information above has been communicated with me, I had the opportunity to ask questions, I had the opportunity to have my prescriptions transferred to another pharmacy in lieu of agreeing to have HealthDyne Pharmacy Inc. fulfill the prescription, and I have the opportunity to transfer my prescriptions to another pharmacy at any point in the future regardless of my agreement to the terms of service.