Eligibility For Patients

Required Field*

Are you a United States Resident?*

Yes

This field is required. Please make a selection

Do you currently have commercial health insurance for a portion of your prescription drug cost?*

Yes

This field is required. Please make a selection

Are you 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

This field is required. Please make a selection

*By activating the Co-pay card, you agree to the following statements:

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

I agree to the information above and I accept the Program Terms, Conditions, and Eligibility Criteria.

This field is required. Please make a selection

Required Field*

First Name*

Please enter your first name

Last Name*

Please enter your last name

Caregiver

Date of Birth*

Please enter your date of birth

Please enter valid date of birth

Gender*

Male

Female

Please make a selection

Address*

Please enter your address

Address 2

City*

Please enter your city

State*

Please enter your state

Zip*

Please enter your zip

Please enter a valid zip

Contact Phone*

Please enter your phone number

Please enter valid phone number

Email Address*

Please enter your email address

Please enter valid email address

Confirm Email Address*

Please confirm your email address

Please confirm valid email address

Email and confirm email do not match

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

Yes, I agree

No, I do not agree

Please indicate if you agree 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.