![]() ORGOVYX is contraindicated in patients with severe hypersensitivity to relugolix or to any of the product IMPORTANT SAFETY INFORMATION & INDICATION Contraindication The ORGOVYX Copay Program is valid through December 31, 2024. ![]() Myovant Sciences reserves the right to revoke, rescind, or amend this offer without notice. Patient and participating pharmacists agree to report the receipt of Copay Program benefits to any insurer or other third party who pays for or reimburses any part of the prescription filled using the Card, as may be required by such insurer or third party. Patient and participating pharmacists agree not to seek reimbursement for all, or any part of the benefit received by the patient through this Copay Program. This offer is not conditioned on any past, present, or future purchase, including refills. This offer cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer. This Copay Program is void where prohibited by state law and on the date an AB generic equivalent for ORGOVYX becomes available. Patient must be a resident of the U.S., Puerto Rico, or U.S. Offer is not valid for cash-paying patients. The Copay Program is not valid for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, Puerto Rico Government Insurance, or any state patient or pharmaceutical assistance program. This Copay Program may not be redeemed more than once per 21 days. After the annual maximum of $10,000 for ORGOVYX is reached, patient will be responsible for the remaining monthly out-of-pocket costs. With this Copay Program, eligible patients will pay as little as $10 per month, subject to a maximum of $10,000 per calendar year. *The ORGOVYX Copay Assistance Program (“Copay Program”) is for eligible patients with commercial prescription insurance for ORGOVYX. Copy of signed federal tax return from most recent tax year (pages 1 & 2 only) In the rare case that you are unable to provide a federal tax return from most recent year, we can consider alternate documents to verify your income.ORGOVYX COPAY ASSISTANCE PROGRAM: TERMS AND CONDITIONS Physician Form, completed and signed by your treating physician 3. Required Documentation: In order to make a final eligibility determination on your application, the following information is all that you need: 1. The program continues to provide personalized assistance through a dedicated professional representative, by phone, who will guide them through the application process and answer any questions you may have. The program offers online service for patients, providers and pharmacies allowing them to apply electronically through a secured, web-based application portal available 24 hours a day. Patient will be informed immediately upon application if they qualify for assistance.Īpplication Process: CPR offers four (4) points of entry into the program accepting applications daily. All funds have income guidelines of either 300% or 400% or less of the Federal Poverty Guideline (FPG) with consideration for the Cost of Living Index (COLI) and the number in the household. Patient's income must fall below the income guidelines of the fund under which they are requesting financial assistance. Patient must reside and receive treatment in the United States. Patient must have a physician confirmed diagnosis of the disease under which they are requesting financial assistance. * Operating as an independent division within PAF, this program provides direct financial assistance with co-payments, co-insurance and deductibles required by your insurer for pharmaceutical treatments and/or prescription medications relative to your diagnosis.Įligibility: Patient must be currently insured and have coverage for the medication(s) for which they seek financial assistance.
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