Patient Support for Xatmep^®

*Eligibility Restrictions, Terms, and Conditions

By participating in this savings program, participants understand and agree that the information provided, as well as non-personally identifiable information obtained from the pharmacy, will be shared with the manufacturer and with any companies working with the manufacturer. Participants also affirm that they will not submit, and have not had submitted on their behalf, a claim for reimbursement or coverage for items purchased with this card under Medicaid, Medicare, TRICARE, or any other federal or state government healthcare program, or where prohibited by state law.

• Commercially insured patients may pay as little as $5. Offer applies to out‐of‐pocket expenses (co‐pay) greater than $5. Benefit limitations apply.
• Offer applies only to Xatmep® patients and associated refills.
• This offer is not valid for prescriptions paid in part or in full by any federally or state‐funded program, including but not limited to Medicaid, Medicare, Department of Veterans Affairs, Department of Defense, or TRICARE, and where prohibited by law.
• This savings program cannot be combined with any other coupon, cash discount card, certificate, voucher, or similar offer.
• Offer good only in the USA at participating retail pharmacies and cannot be redeemed at government‐subsidized clinics. Void where taxed, restricted, or prohibited by law.
• Offer not extended to clubs, groups, or organizations.
• Participation in this program must comply with all applicable laws and contractual or other obligations as a pharmacy provider.
• This is not an insurance program.
• Participating patients and pharmacists understand and agree to comply with the Terms and Conditions of this offer as set forth herein.
• Any step‐edits or prior authorizations required by the insurance plan still apply.
• Azurity Pharmaceuticals, Inc. reserves the right to modify or cancel this program at any time.
• eVoucherRx™ and Voucher on Demand™ are not extended on prescriptions for patients:
  • who are cash‐paying customers.
  • using institution-based pharmacies to fill their prescriptions, or who are recipients of federal or state government health care.
  • who are filling their prescriptions at nonparticipating pharmacies.

eVoucherRx™ is a trademark of RelayHealth.
Voucher on Demand™ is a trademark of eRx Network, LLC.