ACTIVATION SITE

Welcome

This program is only available to residents of the United States and Puerto Rico, except where prohibited. This program is valid for most eligible commercially insured patients. Individuals who are enrolled in or eligible for reimbursement under a government health care program, including Medicare, are not eligible to participate in this program. Terms, conditions and limitations apply. If your insurance changes, you may no longer be eligible to use this offer.

Please answer the following questions:

Choose 1

Do you have a copay card?

Yes

ALL FIELDS REQUIRED

Please enter the 11-digit ID# from the card you received

Please enter a valid 11-digit ID#.

I certify that the patient, or caregiver activating on behalf of the patient, is 18 years or older and understand that any person 65 years of age or older without commercial insurance is not eligible to receive this offer.

Yes

All questions are required

Is the patient who will be using this card eligible for reimbursement of prescriptions (in whole or in part) under any federal, state or other government programs including, but not limited to, Medicare (including Medicare Advantage and Part A, B and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare benefits programs?

Yes

All questions are required

Please confirm that, by clicking submit below to activate this card, you have read, understand and will comply with the terms and conditions of the program, that you currently meet all eligibility criteria and have read and agree with the Privacy Policy.

Yes

All questions are required

Submit

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