$0 Co-Pay 
Program
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Reducing out-of-pocket costs for your patients

To help cover the out-of-pocket costs of CUVPOSA, the CUVPOSA Co-Pay Program may help qualified patients pay as little as $0 each time they fill a prescription.

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*Eligibility, Terms and Conditions, and Program Limitations

From and after January 1, 2018, the Program covers eligible patients’ actual out-of-pocket CUVPOSA medication costs up to a maximum amount of $100 per valid prescription issued and filled during a 12 month period beginning on January 1. The Program card maximum usage is limited to twelve (12) thirty (30) day supply uses or twenty-four (24) fifteen (15) day supply uses per card. The Program card will expire at the end of the calendar year and patients will need to re-enroll into the program as of January 1 of the following calendar year. The Program does not cover (a) office visit co-pays; (b) facility co-pays; or (c) any other costs excluded by the Program guidelines not specifically mentioned herein, which are subject to change.

Original Program card must be presented to the pharmacist at the time each prescription is filled and is good for use only with a valid prescription for CUVPOSA. Not valid if reproduced. It is a violation of law to buy, sell, or counterfeit the CUVPOSA Program Card.

Eligible patients must be clinically appropriate patients for therapeutic treatment with CUVPOSA. Patient must be prescribed CUVPOSA by a licensed healthcare provider. Eligible patients must be at least 3 years of age and less than 17 years of age.

This offer is valid only in the United States, Puerto Rico and in U.S. territories, excluding where it is otherwise prohibited by law. Patients residing in the states of Massachusetts, Michigan, Rhode Island, and Minnesota are eligible for drug co-payment assistance only and are not eligible for other types of co-payment assistance, including but not limited to costs related to administration of the drug. Void where prohibited by law, taxed or restricted.

Eligible patients must have private commercial insurance that covers medication costs for CUVPOSA, and acceptance of this offer must be consistent with the terms of that insurer’s drug benefit. Eligible patients must not have coverage for CUVPOSA through Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), the Department of Defense (DoD), or other federally funded or state funded healthcare programs. Patients who move from commercial to federally funded or state funded insurance will no longer be eligible for the Program. If a patient is enrolled in a state or federally funded prescription insurance program, then the patient is not eligible even if the patient elects to be processed as an uninsured (cash-paying) patient. If a patient is enrolled in a private indemnity or HMO insurance plan that reimburses the patient for the entire cost of the patient’s prescription drugs, then the patient is not eligible to participate even if the patient elects to be processed as an uninsured (cash-paying) patient. This offer is not valid for cash-paying patients.

Patient may not seek reimbursement for value received from the Program from any third-party payers, including flexible spending accounts or healthcare savings accounts.

If at any time Patient begins receiving coverage under any federal, state or government funded healthcare program, Patient is no longer eligible to participate in the Program and Patient’s legal guardian must call at 1-855-740-3040 between 8 AM and 5 PM (ET) to stop participation. Restrictions may apply. This is not health insurance.

Patient’s legal guardian and Patient’s pharmacist is responsible for notifying insurance carriers or any other third party who pays for or reimburses any part of the prescription filled using the Program as may be required by the insurance carrier’s terms and conditions and applicable law.

Enrollment in the Program may be reviewed on an annual basis to determine continued eligibility. This offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer for CUVPOSA.

This is a limited time offer, and Merz reserves the right to rescind, revoke, amend, or terminate this offer, or the program in its entirety, at any time without notice.