Patient Information

Activation

Required Field

The patient is a United States Resident.

Yes

The patient currently has commercial health insurance for a portion of his/her prescription drug cost.

Yes

The patient is NOT enrolled in any federal or state subsidized healthcare program that covers a portion of my 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

*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 drugs.
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.

VITRAKVI $0 CO-PAY PROGRAM TERMS & CONDITIONS

- Patient must meet the eligibility requirements of the VITRAKVI $0 Co-pay Program; for example, only commercially insured patients are eligible

- Patient must inform VITRAKVI $0 Co-pay Program of change in insurance status

- It is required that the patient understand, accept and meet the terms of all the VITRAKVI $0 Co-pay Program requirements

- Use of the VITRAKVI $0 Co-pay Program must be consistent with and not prohibited by the requirements of the patient’s health insurance

- The VITRAKVI $0 Co-pay Program benefit has a max amount of $25,000 per year, per patient

- The VITRAKVI $0 Co-pay Program is for commercially insured patients using VITRAKVI^® for an approved FDA indication

- The VITRAKVI $0 Co-pay Program does not cover costs for charges associated with administering VITRAKVI^® or 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, equitable distribute product and may change or end the VITRAKVI $0 Co-pay Program at any time with or without notice

- Patient agrees to provide necessary health information to the administrators of the VITRAKVI $0 Co-pay Program

- For questions about the VITRAKVI $0 Co-pay Program, please call us at 1-647-245-5637

*Eligible patients may pay as little as $0 and save up to $25,000 per year. Patients who are enrolled in any type of government insurance or reimbursement programs are not eligible. As a condition precedent of the co-payment support provided under this program, e.g., co-pay refunds, participating patients and pharmacies are obligated to inform insurance companies and third-party payers of any benefits they receive and the value of this program, and may not participate if this program is prohibited by or conflicts with their private insurance policy, as required by contract or otherwise. Void where prohibited by law, taxed, or restricted. Patients enrolled in the Bayer US Patient Assistance Foundation are not eligible. Bayer may determine eligibility, monitor participation, equitably distribute product and modify or discontinue any aspect of the VITRAKVI $0 Co-Pay Program at any time, including but not limited to this commercial co-pay assistance program.