GEMTESA COPAY ASSISTANCE PROGRAM: TERMS, CONDITIONS AND ELIGIBILITY CRITERIA

To be eligible for the GEMTESA Copay Assistance Program (“Copay Program”), patients must have commercial prescription insurance, have a valid prescription for an FDA-approved indication of GEMTESA, be 18 years or older, and be a resident of the US, Puerto Rico, or US Territories.
The Copay Program is not valid for patients enrolled in 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 pharmaceutical assistance program. 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. Offer is not valid for cash-paying patients.
The benefit under the Copay Program is offered to, and intended for the sole benefit of, eligible patients and may not be transferred to or utilized for the benefit of third parties, including, without limitation, third party payers, pharmacy benefit managers, or the agents of either.
The Copay Card cannot be combined with any other external savings, free trial, or similar offer for the specified prescription (including any program offered by a third-party payer or pharmacy benefit manager, or an agent of either, that adjusts patient cost-sharing obligations, through arrangements that may be referred to as “accumulator” or “maximizer” programs).
Third-party payers, pharmacy benefit managers, or the agents of either, are prohibited from assisting patients with enrolling in the Copay Program.
The actual application and use of the benefit available under the Copay Program may vary on a monthly, quarterly, and/or annual basis depending on each individual patient’s plan of insurance and other prescription drug costs. This Copay Program is subject to change or discontinuation without any notice.
In some instances, savings may be applied without submitting a claim to your insurer and your copayment may not be applied to your insurance deductible. Patients should inquire at the pharmacy to determine whether their insurance has been applied.
Depending on your insurance coverage:
- Most commercially insured patients who have coverage for GEMTESA pay as little as $10 for each 30-day supply or as little as $0 for each 90-day supply between January 1, 2026 and December 31, 2026. Maximum savings limit for covered claims is $421 for each 30-day supply or $1,263 for each 90-day supply; final patient out-of-pocket expense will vary.
- Most commercially insured patients who do not have coverage for GEMTESA pay as little as $95 for each 30-day supply. Maximum savings limit for not-covered claims is $454 for each 30-day supply; final out-of-pocket expense will vary.
This card is valid for up to 12 prescription fills for a 30-day supply or 4 prescription fills for a 90-day supply.
The Copay Program is good only in the US, Puerto Rico, or US Territories at participating pharmacies. This Copay Program is void where prohibited by law and on the date an AB-rated generic equivalent for GEMTESA becomes available.
This offer is not health insurance.
This offer has no cash value and cannot be combined with any other coupon, free trial, discount, prescription savings card, or other similar offer for the specified prescription.
This offer is not conditioned on any past or future purchase, including refills.
This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.
Patient and participating pharmacists agree not to seek reimbursement from any insurer or third party for all or any part of the benefit received by the patient through this Copay Program.
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 Copay Program, as may be required by such insurer or third party.
Sumitomo Pharma America reserves the right to revoke, rescind, or amend this offer without notice.
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 1-833-876-8268.

Pharmacy Instructions

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 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. Offer not valid for discount cards, and patients without insurance or who elect not to use their insurance at the pharmacy.
Valid Other Coverage Code required. For any questions regarding online processing, please call the Help Desk at 1-312-748-0914.

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