REPRINT PREVIOUSLY ISSUED APTIOM CARDS

Please enter the email address you used to enroll with Sunovion Answers for APTIOM® in the box below. If you’re unable or unwilling to provide this information, you can call 1-844-4APTIOM (1-844-427-8466) 8 AM to 8 PM ET, Monday through Friday.

HAVE QUESTIONS?

If you have any questions regarding your APTIOM Savings Card, contact your Sunovion Answers for APTIOM Support Specialist 8 AM to 8 PM ET, Monday through Friday.

1-844-4APTIOM (1-844-427-8466)

If you have questions about your High-Deductible Discount Card, call 1-855-820-0071, 8 AM to 8 PM ET, Monday through Friday.

VOUCHER TERMS AND CONDITIONS:

  • You must be 18 years of age or older to accept this offer. This offer is valid only for eligible patients and legal guardians of eligible patients. Patients must have a valid prescription for APTIOM within APTIOM's approved indication
  • This voucher is valid for a 14-day supply of APTIOM
  • Limit 1 voucher per patient per lifetime
  • No purchase necessary. Refills are not required
  • This voucher is not transferable. No substitutions are permitted. This offer cannot be combined with any other free trial, coupon, discount, prescription savings card, or other offer
  • This voucher is not health insurance. Claim shall not be submitted to any public or private third-party payer or any federal or state health care program for reimbursement
  • Offer valid only in the United States and Puerto Rico. Void where prohibited by law, taxed, or restricted
  • It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit this voucher. Void if reproduced
  • Sunovion reserves the right to rescind, revoke, or amend this offer at any time without notice

To the Patient: Present this voucher to the pharmacist at a participating pharmacy, along with your valid prescription from a health care professional. Limitations apply. Please see Terms and Conditions. Need help? Call 1-800-657-7613 (8 AM–8 PM ET, Monday–Friday).

To the Pharmacist: Must be accompanied by a valid prescription for 14-day supply of APTIOM. Prescriber ID# required on prescription. Dispense as written with no cost to the patient. For reimbursement, submit claim to McKesson Corporation using BIN #610524. Do not submit to any other payer, public or private, for reimbursement. For pharmacy processing questions, please call the McKesson Help Desk at 1-800-657-7613 (8 AM–8 PM ET, Monday–Friday).

HIGH-DEDUCTIBLE DISCOUNT CARD PROGRAM TERMS AND CONDITIONS:

  • This offer is valid only for eligible patients 18 years of age or older, or legal guardians of patients between 4 and 17 years of age with a valid prescription for APTIOM
  • Offer limited to one per person and may not be used with any other offer for APTIOM
  • High-deductible commercial insurance required
  • Cash-paying patients are not eligible
  • Patients are not eligible if prescriptions are paid in part or full by any state or federally funded health care programs, including but not limited to Medicare, Medicaid, VA, DOD, or TRICARE, or where prohibited by law
  • Activation is required to use this card
  • This card is valid for up to $500 off each of up to 3 qualifying prescriptions for up to a 30-day supply, and may not be used with any other offer. Patient is responsible for the first $35 of their co-pay and any additional out-of-pocket costs above $500
  • For patients using this card for a 90-day prescription fill, this card may only be used one time
  • This program is not health insurance
  • Offer valid only in the United States and Puerto Rico. Void where prohibited by law, taxed, or restricted
  • Sunovion reserves the right to rescind, revoke, or amend this offer at any time without notice. This offer is not transferable and may not be sold, purchased, or traded, or offered for sale, purchase, or trade
  • Offer expires 12/31/2018

To the Patient: You must present this card to the pharmacist along with your APTIOM prescription to participate in this program. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the APTIOM High-Deductible Discount Card program at 1-855-820-0071 from 8 AM to 8 PM ET, Monday through Friday. When you use this card, you are certifying that you have read the program rules, regulations, and terms and conditions; you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription; if you are Medicare eligible, you are not enrolled in an employer-sponsored health plan or prescription drug plan for retirees; and you will otherwise comply with the terms above.

To the Pharmacist: When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription.

  • Submit transaction to McKesson Corporation using BIN #610524
  • Patient must be covered by Commercial Prescription Insurance. Input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response
  • Acceptance of this card and your submission of claims for the program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc
  • For questions regarding setup, claim transmission, patient eligibility, or other issues, call the LoyaltyScript® Discount Card program at 1-855-820-0071, Monday through Friday, 8 AM to 8 PM ET

SAVINGS CARD TERMS AND CONDITIONS:

By using this card, you acknowledge that you currently meet the following eligibility requirements:

  • You must be 18 years of age or older to accept this offer. This offer is valid only for eligible patients and legal guardians of eligible patients. Patients must have a valid prescription for APTIOM within APTIOM's approved indication
  • Offer not valid if prescription is paid in part or full by any state or federally funded health care program, including but not limited to Medicare, Medicaid, VA, DOD or TRICARE, or where prohibited by law
  • This card is valid for up to $75 off each prescription fill for up to a 30-day supply. The card is further limited to twelve (12) qualifying prescription fills per calendar year
  • Offer is limited to one per person and may not be used with any other offer
  • This program is not health insurance. The amount of the benefit cannot exceed the patient's out-of-pocket expenses. Acceptance of this offer must be consistent with the terms of any drug benefit provided by a health insurer, health plan, or other third-party payer. If requested or required by any such payer, the patient must report the use of this card. The patient must deduct the value of the savings received under this program from any reimbursement request submitted to the patient's insurance plan, either directly or on the patient's behalf
  • For California and Massachusetts residents, benefits pursuant to this card will terminate automatically upon the introduction of a therapeutically equivalent product
  • Offer valid only in the United States and Puerto Rico. Void where prohibited by law, taxed or restricted
  • Sunovion reserves the right to rescind, revoke or amend this offer at any time without notice. This offer is not transferable and may not be sold, purchased or traded, or offered for sale, purchase or trade

To the Patient: You must present this card to the pharmacist along with your prescription to participate in this program. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the APTIOM Savings Card program at 1-844-4APTIOM (1-844-427-8466) anytime between 8 AM to 8 PM ET, Monday through Friday. By using this card, you are certifying that you understand the enclosed program rules, regulations, and terms and conditions; you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental program for this prescription or where otherwise prohibited by law in your state; and you will otherwise comply with the terms mentioned herein.

To the Pharmacist: When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental program for this prescription.

  • Submit transaction to McKesson Corporation using BIN # 610524
  • If primary commercial prescription insurance exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response
  • Acceptance of this card and your submission of claims for the program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc
  • Patient is not eligible if prescriptions are paid in part or full by any state or federally funded health care program, including but not limited to Medicare or Medicaid, VA, DOD or TRICARE, or where prohibited by law
  • For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® Savings Card program at 1-866-279-8992, 8 AM–8 PM ET, Monday through Friday

Sunovion reserves the right to rescind, revoke or amend this offer at any time without notice.

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