To receive co-pay assistance of up to $250 for each prescription filled, please accurately answer the questions below:

Please fill in or correct the following fields

Please enter your 5-digit numeric zip code.

Please enter a valid e-mail address.

Patient Name:

Patient Address:

City:

State:

ZIP Code:

Please see Important Safety Information, including Boxed Warning and full Prescribing Information, at https://www.otrexup.com/.

To insure each patient is benefiting from the Otrexup Total Care Co-Pay Assistance Program, Antares Pharma, Inc. would like to notify you about updates to the program by email. Please see Important Safety Information when the coupon is printed.

Email Address:

Antares Pharma, Inc. respects your privacy and any information provided to us. Information will only be used by Antares Pharma, Inc. and its contracted third parties. Antares Pharma won’t sell or transfer your personal information to any party other than Antares affiliates and third parties contracted to support the Otrexup Total Care Co-Pay Assistance Program.

OTX-197-15-01