NEW PATIENT ELIGIBILITY

Terms and Conditions:

  1. This offer is valid for commercially-insured as well as cash paying patients.
  2. Depending on insurance coverage, eligible insured patients may pay no more than $50 for Injectafer for the first dose and $0 for Injectafer for the second dose, up to a maximum savings limit of $500 per dose, a $1,000 program limit for coverage up to two doses. Check with your pharmacist or healthcare provider for your copay discount. Patient out-of-pocket expense may vary.
  3. This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees.
  4. The offer is valid for 1-course, or two doses, of an Injectafer prescription. An explanation of benefits statement must be faxed in prior to transacting on the account numbers for assistance. The account number may be used for additional course of therapy only after re-enrolling. One re-enrollment is allowed per 12-month period.
  5. Daiichi Sankyo, Inc. reserves the right to rescind, revoke, or amend this offer without notice.
  6. Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers.
  7. Void if prohibited by law, taxed, or restricted.
  8. This account number is not transferable. The selling, purchasing, trading, or counterfeiting of this account number is prohibited by law.
  9. This account number is not insurance.
  10. By redeeming this account number, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.
  11. Qualified patients receiving Injectafer will be allowed a 30-day retroactive enrollment period to receive benefits under the program rules. Any patient wishing to receive this retroactive enrollment assistance must fill out the Eligibility Attestation Form to submit along with the claim from their initial treatment. This form must be completed prior to receiving any copay assistance.