Spravato Patient Financial Responsibility

Patient Financial Responsibility and Acknowledgement – SPRAVATO® (Esketamine)I understand that by signing this Patient Financial Responsibility Agreement, I consent to the terms and conditions set forth below regarding the medical [and/or psychotherapy] services, including administration of the only FDA-approved esketamine treatment, SPRAVATO®(the “Therapies”), that I will receive from providers using the Journey Clinical, Inc. (“Journey”) platform. “Providers” shall include physicians, therapists, and nurse practitioners employed or engaged by Journey Clinical Psychiatry, P.C., Inc., Journey Clinical Psychiatry CA, P.C., and Journey Clinical Psychiatry, TX, PLLC [and affiliated psychotherapists] . Providers will administer the Therapies at Risk Evaluation & Mitigation Strategy (“REMS”) certified outpatient healthcare settings (each a “Center”).

I acknowledge and agree as follows:

To be eligible for treatment with SPRAVATO®, I must undergo a SPRAVATO® consultation and enroll in the SPRAVATO® REMS Program by submitting a Provider Enrollment Form to Janssen Pharmaceuticals, Inc. I understand that my Provider will assist me in filling out this form and submit it on my behalf.While Journey itself is not a Provider, Journey is responsible for providing the administrative function of billing for all services provided by Journey-affiliated Providers, including SPRAVATO® treatment visits and the costs of the drug itself.

If I have a health insurance policy that I plan to use to receive covered medical services, including administration of SPRAVATO® (“Covered Services”) from Providers affiliated with Journey, I have provided Journey with the most updated and correct information about my insurance. If I provide Journey with incorrect or not current information about my insurance, I will be fully responsible for any and all charges for the cost of services, including the Therapies, provided to me through the Journey platform.

To be treated with SPRAVATO®, I understand that prior authorization is commonly required by insurance plans. During my pre-treatment consultation, I will work with Journey to identify and verify my patient benefits and obtain any required prior authorizations from my health insurance plan.

I assume full financial responsibility and agree to pay for all charges for Covered Services that are not paid by insurance, including co-payments, co-insurance and/or deductibles and expenses of every kind and description for all Covered Services provided to me by Providers affiliated with Journey. I know that this includes all payments required under my insurance plan. I agree it is my responsibility to confirm that the Center where I will receive the Therapies through Providers affiliated with Journey is in-network under my health insurance policy.

I acknowledge that my treatment visit and administration of SPRAVATO® may not be covered by insurance (“Non-Covered Services”) and that I am solely financially responsible for any Non-Covered Services. If I need financial support or assistance, I can sign up for the SPRAVATO® withMe program offered by Janssen Pharmaceuticals, Inc. by calling 1-844-479-4846, Monday through Friday, 8:00 AM – 8:00 PM ET.

I further understand that SPRAVATO® (esketamine) is billed differently from other services that are offered through the Providers using Journey’s platform, including Ketamine Assisted Psychotherapy , and that cost-sharing obligations vary by insurance plan.If I am using health insurance to cover my treatment, Journey will be responsible for billing my insurer for my treatment visit and the SPRAVATO® itself on the day I receive treatment.

Payment for any and all charges related to Covered and Non-Covered Services, including co-insurance and co-pays, from Journey or Providers affiliated with Journey will be due either prior to the beginning of my session or immediately thereafter, as instructed by Journey. If I receive any bill from Journey or a Journey-affiliated Provider for amounts due that have been unpaid, I agree to pay any such bill within the stated reasonably expected time.

Journey accepts most major credit cards and payments via its third-party online payment processing vendor.If I have a health insurance policy, I have carefully read the section in my health insurance policy that describes Covered Services. If I have questions about my coverage, I will call the plan administrator to ask questions and clarify my benefits. I am responsible for knowing which services my insurance plan will and will not cover, my financial responsibility (out-of-pocket charges), whether my visit will be covered under my medical plan or if I have a behavioral health benefit, whether the Center is in-network, and whether SPRAVATO® is covered under my medical or pharmacy benefit. It is my responsibility to have obtained any and all necessary referrals and authorizations required prior to receiving medical services from Providers affiliated with Journey, including the administration of SPRAVATO®. If my insurance company requires a referral and I do not have one, then I understand that I will be responsible for all the costs and fees associated with the services I receive.

I may incur additional charges at the discretion and reasonable notice of Journey, including without limitation charges for credit card payment processing fees, missed appointments without notice per Journey’s policies, which are subject to change, and any costs associated with the collection of unpaid balances.

I authorize Journey and Providers affiliated with Journey to release my medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, other third-party payors, and/or other physicians or healthcare entities required to participate in my care.

I authorize assignment of my insurance benefits to be paid directly to Journey and Providers affiliated with Journey for any services rendered as allowable under standard insurance and other third-party payor contracts.

I understand I am financially responsible for charges not covered by this assignment. If I receive payment from my insurance plan for benefits due to Journey or its affiliated Providers for my care, other than as reimbursement for payments I have already made, I agree to promptly sign the payment to Journey, or pay that amount to Journey directly.

I understand that SPRAVATO® (esketamine) is an FDA-approved medication that is dispensed exclusively to a Center and is administered only in a Center under direct supervision. SPRAVATO® is never dispensed directly to patients and cannot be taken home. There will never be shipping or home-delivery charges associated with SPRAVATO®. Charges for SPRAVATO® treatment reflect the cost of the drug, in-office administration, supervision, and required post-dose monitoring.

I understand that I am personally responsible to pay for my care received via the Journey platform for Non-Covered services if I do not have insurance, Journey does not participate in my health insurance plan or my insurance does not pay for my care because:

My health plan requires my primary care physician to give me a written referral before a Journey-affiliated Provider treats me and I did not get a referral;

My health plan denies payment for these services and leaves me responsible for payment;My health plan decides that services I received via the Journey platform are not medically necessary and/or Non-Covered Services;

My health plan denies or does not approve prior authorization for SPRAVATO® treatment;

My health plan coverage has lapsed or expired at the time I receive services via the Journey platform; orI have chosen not to use my health plan coverage.

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I understand that the terms herein are contractual and not a mere recital and that I sign this document as my own free act and void of any coercion.

I understand that clicking “I Agree” constitutes a legal signature and verifies that I have read all of the information contained in this Patient Financial Responsibility Agreement.Journey Clinical Insurance PoliciesWhat does Insurance Cover at Journey Clinical?Journey Clinical offers a variety of services to support your unique needs, and insurance coverage will differ based on the type of service that we provide you. Here are some simple guidelines:Covered services: Clinician Visits with Journey Clinical (Initial Consultations and Follow-up Visits), as well as treatment visits and SPRAVATO® itself, may be eligible for coverage by your insurance plan.

Therapy sessions are covered by insurance for some therapists. We submit these claims to your insurance company at the completion of your appointment. Any remaining payment responsibility, such as a copay, will be billed to you after the services are completed. You must verify and understand your eligibility and copay responsibility as well as provide credit card information for

Non-Covered services, by emailing patient-billing@journey.clinic prior to your therapist submitting claims to insurance.Non-Covered services: Journey Clinical’s digital tools, and on-demand services are not covered by insurance plans. Some insurers will not cover Treatment Visits and SPRAVATO® itself. For non-SPRAVATO® prescription medications, we can send the prescription to your local pharmacy so they can assess your insurance coverage.

What is your refund and cancellation policy if I pay with insurance?

For Journey Clinical-covered therapy sessions, appointments must be canceled or rescheduled at least 24 hours in advance of the session to avoid any charges. You will be considered a no-show if you are more than 15 minutes late to your scheduled appointment. To reschedule or cancel an appointment, please contact your therapist.If you cancel with less than 24 hours’ notice or miss your scheduled appointment, you will be charged a cancellation fee of $82.5 per hour. The cancellation fee is not eligible for insurance reimbursement.

For Journey Clinical Medical Appointments, if your appointment is more than 72 hours (3 days) away, you can reschedule or cancel for free. Log in to your Patient Portal, and on your Homepage you’ll see your consultation date and time. Select ‘Manage appointment’ and follow the prompts to reschedule.

Important: If you reschedule or cancel a consultation within 72 hours (3 days) of the scheduled start time, you will be charged a cancellation fee. To do this, contact the Journey Clinical Patient Support Team for assistance at patient-support@journey.clinic.

If you used insurance to pay, the cancellation policy for Initial Evaluation and Follow Up:

0–72 hours before appointment time

- Charged $200 for late cancellation fee

- Charged $150 for late cancellation fee

73 or more hours before appointment time

- No Fee

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Refunds may take 5-10 business days to be processed.