*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.