KEVZARA can lower the ability of your immune system to fight infections. SERIOUS INFECTIONS: KEVZARA is a medicine that affects your immune system. Important Safety Information KEVZARA® (sarilumab) can cause serious side effects including: Acceptance of this offer and your submission of claims are subject to the Terms and Conditions posted at For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for KEVZARA program at 1‑844‑KEVZARA.īY USING THIS COPAY CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS Will be displayed in the transaction response. Submit transaction to RxC Acquisition Company d/b/a RxCrossroads by McKesson using BIN #610524. If primary commercial prescription insurance exists, input offer information as secondaryĬoverage and transmit using the COB segment of the NCPDP transaction. Copay cards must be accompanied by a prescription for KEVZARA. Pharmacist will comply with his/her obligations when processing the prescription for payment. Or other government programs for this prescription. Pharmacist Instructions: When you use this offer, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, For questions regarding your eligibility or benefits or if you wish to discontinue your participation, To ensure compliance with laws pertaining to any government funded program. This program is not valid where prohibited by law.īy redeeming this coupon, you are certifying that (1) you are not a beneficiary of any government funded program as noted above (2) should you begin receiving prescription benefitsįrom any government funded program, you will withdraw from this program and (3) you acknowledge and understand that adherence to the terms and conditions of this offer is necessary Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including any state pharmaceutical assistance program. This offer is not valid for prescriptions covered by or submitted for reimbursement under Insurance, you may need to notify the insurance carrier of redemption of this copay card. Program is not valid for cash paying customers. Patient Instructions: KEVZARA must be covered by your commercial insurance. Questions or concerns about deductible, copay, or coinsurance amounts or the ability to obtain KEVZARA? Contact KevzaraConnect® at 1‑844‑KEVZARA. This program is not valid where prohibited by law, taxed or restricted. The copay card is non-transferable, limited to one per person,Īnd cannot be combined with any other offer or discount. This offer is not conditioned on any past, present or future purchase, including refills. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. KevzaraConnect® reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms and conditions at any time without notice. In those situations, the Program may change its terms. Patients may have insurance plans that attempt to dilute the impact of the assistance available under the Program. The Program is intended to help patients afford KEVZARA.
CopayĪmounts after applying copay assistance may depend on the patient’s insurance plan and may vary. The maximum annual patient benefit under the Program is $15,000. General, non-product specific insurance deductiblesĪbove the amount set forth above are also not covered. Procedures, or any physician-related services associated with KEVZARA. It is not an insurance benefit, and does not cover or provide support for supplies, Submitted for reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs includingĪny state pharmaceutical assistance program. This offer is not valid for prescriptions covered by or The District of Columbia, and Puerto Rico, are prescribed KEVZARA® (sarilumab) for an FDA-approved indication,Īnd are insured and covered by a commercial health plan. *This program only applies to patients who are at least 18 years of age, residents of the 50 United States,
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