TO THE PATIENT: To be eligible for this offer: (a) where third-party reimbursement covers a portion of your prescription, this savings card is valid only for the amount of your actual out-of-pocket expenses up to a maximum of $40.00 for each Cuvposa prescription fill, (b) your prescription MUST NOT be covered/reimbursed by a federal healthcare program, including Medicare or Medicaid, or by any similar federal or state program, including a state pharmaceutical assistance program, and (c) you MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). Acceptance of this savings card offer must be consistent with the terms of any insurance benefit. You understand and agree to comply with the terms and conditions of this offer above.
TO THE PHARMACIST: For questions regarding processing, please call 1-855-740-3040. By redeeming this savings card I certify that (i) I have received this savings card from an eligible patient, (ii) I have dispensed the product as indicated, (iii) I have not submitted, and will not submit, a claim for reimbursement to the patient or any federal, state or other governmental payer, and (iv) I will otherwise comply with the terms hereof. I further certify that my participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that I have as a pharmacy provider. I agree to retain processing records for 3 years or as required by law, whichever is longer, and to grant Merz Pharmaceuticals, the right to audit submissions.
PATIENT/PHYSICIAN QUESTIONS: For any questions regarding the $40.00 Cuvposa savings card, please call 1-855-740-3040.