Terms and Conditions for the ONFI 14-Day Free Trial and Copay Assistance Programs
General Terms and Conditions: Only commercially insured patients age 2 and older whose insurance policy provides coverage for ONFI® (clobazam) CIV and who are not reimbursed for the entire cost of the prescription are eligible for the 14-Day Free Trial voucher or copay assistance (the “Offers”). Patients are not eligible for the Offers if they are self-pay or if the prescription is eligible to be reimbursed, in whole or in part, by any state or federal health care programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, or TRICARE. In addition, patients may not use the Offers if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.
Offers are valid only for use with a valid prescription for ONFI at the time the prescription is filled by the pharmacist and dispensed to the patient. Offers apply only to prescriptions filled before the programs expire. The free trial and copay prescriptions shall not be submitted for reimbursement to any public third-party payer, including Medicaid or Medicare or any other similar federal or state healthcare program; in addition, the free trial prescription shall not be submitted to any private third-party payer. Patients are responsible for complying with any obligations or requirements imposed by their insurance plans.
The Offers are not transferable. The selling, purchasing, trading, or counterfeiting of the Offers is prohibited by law. The Offers have 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.
Lundbeck reserves the right to rescind, revoke, or amend the Offers without notice. Offers are intended to comply with all applicable laws and regulations, including, without limitation, the federal Anti-Kickback Statute, its implementing regulations, and related guidance interpreting the federal Anti-Kickback Statute. Offers are not health insurance. Offers are valid only in the USA where allowed by law. There is no future purchase requirement associated with the Offers. Patient questions and requests to discontinue participation in the programs can be directed to 1-855-809-5818 (8:00 AM-8:00 PM ET, Monday through Friday).
14-Day Free Trial Terms and Conditions: To participate in this program, eligible commercially insured patients age 2 and older must present the 14-day Free Trial voucher to the pharmacist along with their valid prescription. By participating in the 14-Day Free Trial, the patient acknowledges and agrees that he/she is eligible to participate and that he/she understands and agrees to comply with the General and 14-Day Free Trial Terms and Conditions.
Copay Assistance Terms and Conditions: Eligible patients must present their activated card to the pharmacist along with their valid ONFI prescription to participate in this program. The offer is valid for up to 12 prescription fills of a 30-day supply each. Use of the Copay Assistance program will require patients to pay a minimum of $10 out-of-pocket expense for each 30-day prescription. To be eligible, patients must have a copay that exceeds $10 for each 30-day prescription. A maximum benefit of $600 may apply for each 30-day prescription. If the patient’s total out-of-pocket pharmacy bill exceeds the cap established by Lundbeck, the patient will be responsible for the additional balance. Patients should talk to their pharmacist to determine the maximum amount that they could pay based on their prescribed dosage and insurance benefits. By participating in the Copay Assistance program, the patient acknowledges and agrees that he/she is eligible to participate and that he/she understands and agrees to comply with the General and Copay Assistance Terms and Conditions.
To the Pharmacist:
- Submit transaction to McKesson Corporation using BIN #610524
- For the copay card, if primary coverage exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response
- Acceptance of this card and your submission of claims are subject to the LoyaltyScript® program. Terms and Conditions posted at www.mckesson.com/mprstnc
- For questions regarding setup, claim transmission, patient eligibility, or other issues, call the LoyaltyScript® program at 1-855-809-5818 (8:00 AM-8:00 PM ET, Monday through Friday)