START SAVING WITH your GEMTESA® Simple Savings Card!

GEMTESA® SIMPLE
SAVINGS PROGRAM

Member ID:

Group #: TCWGEM1

BIN #: 637765

PCN #: CRX

After your first prescription, continue to save on refills:

  • You have commercial insurance
    (government plans like Medicare or Medicaid are not eligible)
  • GEMTESA is covered by your plan
  • You have commercial insurance
    (government plans like Medicare or
    Medicaid are not eligible)
  • GEMTESA is not covered by your plan

*See full program terms, conditions, and eligibility criteria below.

PROGRAM TERMS, CONDITIONS, AND ELIGIBILITY CRITERIA

  1. This offer is valid only for eligible patients and is good for use only with a
    valid prescription for GEMTESA at the time the prescription is filled by the
    pharmacist and dispensed to the patient.
  2. Depending on your insurance coverage, most commercial patients for whom
    GEMTESA is covered pay as little as $10 and most commercial patients for
    who GEMTESA is not covered pay as little as $95. Maximum savings limits
    apply; patient out-of-pocket expense will vary.
  3. This card is valid for up to 12 prescription fills.
  4. This card expires one-year from activation date.
  5. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or
    other federal or state programs (including any state pharmaceutical
    assistance programs), or private indemnity or HMO Insurance plans that
    reimburse the patient for the entire cost of the prescription drugs. Patients
    may not use this offer if they are Medicare-eligible and enrolled in an
    employer-sponsored health plan or prescription drug benefit program for
    retirees. This offer is not valid for cash-paying patients.
  6. Urovant Sciences reserves the right to rescind, revoke, or amend this offer
    without notice.
  7. Offer good only in the USA, including Puerto Rico, at participating
    retail pharmacies.
  8. Void where prohibited by law, taxed, or restricted.
  9. This card is not transferable. The selling, purchasing, trading, or
    counterfeiting of this card is prohibited by law.
  1. This card has no cash value and may not be used in combination with
    any other discount, coupon, rebate, free trial, or similar offer for the
    specified prescription.
  2. This offer is not health insurance.
  3. By redeeming this card, you acknowledge that you are an eligible patient
    and that you understand and agree to comply with the terms and
    conditions of this offer.

For questions about this program please call 1-833-UROVANT (876-8268).

Pharmacist Instructions for a patient with an eligible third-party payer: When
you redeem this card, you certify that you have not submitted and will not
submit a claim for reimbursement under any federal, state, or other
government health insurance programs for this prescription.

  • Submit the claim to the primary third-party payer first and then submit the
    balance due to Change Healthcare as a Secondary Payer COB [coordination
    of benefits] with patient responsibility amount and a valid Other Coverage
    Code, (e.g. 3 or 8). The patient’s out-of-pocket expense will be reduced up to
    the maximum savings limit for the program. Reimbursement will be received
    from Change Healthcare.
  • Valid Other Coverage Code required. For any questions regarding Change
    Healthcare
     online processing, please call the Help Desk at 1-800-433-4893.
    Program managed by COMP on behalf of Urovant Sciences Inc.