Eligibility For Your Patients

Required Field *

Is the patient a United States Resident?*

Yes

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Does the patient currently have commercial insurance for a portion of the prescription drug cost? *

Yes

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Is the patient enrolled in any federal or state subsidized healthcare program that covers a portion of your prescription drug costs, including Medicare (such as Medicare Part D prescription drug benefit), Medicaid, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs? *

Yes

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*By activating the co-pay card, your patient agrees to the following statements:

Your patient’s information above is true and correct
Your patient is not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare or Medicaid, or any private indemnity or HMO insurance that reimburses your patient the entire cost of your prescription drug
You agree that your patient is not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees
Should your patient begin receiving prescription benefits from one of these types of programs at any time, your patient will no longer participate in this savings program.

Your patient agrees to the information above and accepts the Program Terms, Conditions, and Eligibility Criteria.

This field is required. Please make a selection

Required Field*

Patient’s First Name*

Please enter the patient’s first name

Patient’s Last Name*

Please enter the patient’s last name

Patient’s Date of Birth*

Please enter the patient’s date of birth

Please enter valid date of birth

Patient’s Gender*

Male

Female

Please make a selection

Patient’s Address*

Please enter the patient’s address

Patient’s Address 2

Patient’s City*

Please enter the patient’s city

Patient’s State*

Please enter the patient’s state

Patient’s Zip*

Please enter the patient’s zip

Please enter the valid patient’s zip

Patient’s Contact Phone*

Please enter the patient’s phone number

Please enter the valid patient’s phone number

Patient’s Email Address*

Please enter the patient’s email addres

Please enter the valid patient’s email address

Confirm Email Address*

Please confirm the patient’s email address

Please confirm the valid patient's email address

Email and confirm email do not match

*My patient agrees that the information provided above is true and correct. My patient understands and agrees that the information provided will be in accordance with Bayer Pharmaceuticals Privacy Statement, including to provide my patient with informational communications from Bayer and/or third party vendors, offers, and promotions and to contact my patient for market research about Kyleena.

Yes, my patient agrees

No, my patient does not agree

Please indicate if the patient agrees with the terms

Co-pay Savings Program for Kyleena TERMS & CONDITIONS

Patient must meet the eligibility requirements of the Co-pay Savings Program for Kyleena; for example, only commercially insured patients are eligible
Patient must inform the Co-pay Savings Program for Kyleena of change in insurance status
It is required that the patient understand, accept, and meet the terms of all the Co-pay Savings Program for Kyleena requirements
Use of the Co-pay Savings Program for Kyleena must be consistent with and not prohibited by the requirements of the patient’s health insurance
The Co-pay Savings Program for Kyleena benefit has a max of $950, per patient
The Co-pay Savings Program for Kyleena is for commercially insured patients using Kyleena for an approved FDA indication
The Co-pay Savings Program for Kyleena does not cover costs for charges associated with patient visits
Offer valid only for patients treated in the USA, including Puerto Rico, Guam and US Territories
Bayer reserves the right to determine eligibility, monitor participation, equitably distribute product and modify or discontinue the Co-pay Savings Program for Kyleena at any time with or without notice
Patient agrees to provide necessary health information to the administrators of the Co-pay Savings Program for Kyleena

For questions about the Co-pay Savings Program for Kyleena, please call us at 1-833-244-2719.