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.
  10. 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.
  11. This offer is not health insurance.
  12. 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 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.

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