DETERMINE ELIGIBILITY FOR THE $0 CO-PAY* CARD

To find out if you are eligible for a myfortic® (mycophenolic acid) delayed-release tablets, Neoral® (cyclosporine capsules, USP) MODIFIED, or SANDIMMUNE® (cyclosporine capsules, USP) $0 Co-Pay Card, simply answer the questions below. Please note that this information must be entered by you or a caregiver, and cannot be entered by a third party.

*Limitations apply. See Program Terms and Conditions. This offer is not valid under Medicare, Medicaid, or any other federal or state
program. Limitations may apply to MA or CA residents. Patients may receive up to $7200 in benefits per brand annually for the life of the program.
If insured patient reaches the max annual cap per brand per calendar year of $7200, patient will be responsible for the difference. This program is
subject to termination or modification at any time.

Eligibility

Personal Info

Done

1.

I certify that I am over the age of 18 and that I am the patient or that I am the patient's caregiver and have the patient's consent to proceed with the enrollment of this savings card.

YES

NO

Patient Ineligible You must be 18 years or older to complete this enrollment form. Please have a parent or caregiver who is at least 18 years of age complete the enrollment process or call 1-877-952-1000.

Patient Ineligible

You must be 18 years or older to complete this enrollment form. Please have a parent or caregiver who is at least 18 years of age complete the enrollment process or call 1-877-952-1000.

2.

Do you have commercial (also known as private) insurance?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as it's only valid for those with commercial insurance. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as it's only valid for those with commercial insurance. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

3.

Are you enrolled in any state or federally funded programs, including but not limited to Medicare, Medicaid, VA, DoD, or Tricare?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as the offer is not valid under Medicare, Medicaid, or any other federal or state program. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as the offer is not valid under Medicare, Medicaid, or any other federal or state program. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

4.

Are you paying cash for the full price of the prescription?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as the offer is not valid for cash-paying patients. Please call 1-877-952-1000

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as the offer is not valid for cash-paying patients. Please call 1-877-952-1000.

5.

Are you a resident of Massachusetts or California?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as the offer is not valid for residents of Massachusetts or California. Please call 1-877-952-1000.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as the offer is not valid for residents of Massachusetts or California. Please call 1-877-952-1000.

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Terms and conditions


*Limitations apply. Valid only for those with private insurance. The Program includes the Co-pay Card, Payment Card (if applicable), and Rebate, with a combined annual limit of $7,200. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, or (iii) where the patients insurance plan reimburses for the entire cost of the drug. The value of this program is exclusively for the benefit of patients and is intended to be credited towards patient out-of- pocket obligations and maximums, including applicable co-payments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. Limitations may apply in CA and MA. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.


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