Please answer a few general questions.

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Which state do you reside in?
State
Please select a State from the list above
Do you participate in any government, state, or federally funded medical or prescription benefit programs?
This includes Medicare, Medicaid, Medigap, VA, Department of Defense, and TRICARE, as well as any other state or federal employee-benefit programs.
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Your card is not valid for prescriptions purchased under Medicaid, Medicare, or any other state or federal employee-benefit programs or where prohibited by law. Should you begin receiving prescription benefits from such federal, state, or government-funded program at any time, you will no longer be eligible to use your Momentum Savings Card. We may contact you by phone or mail periodically in order to verify that your eligibility for the program has not changed. Do you acknowledge your agreement with this statement?
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If you have insurance and plan to use it together with your Momentum Savings Card, please note that your insurance company may require prior notification. Please indicate you agree to notify your insurance company if required.
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Eligibility Restrictions

TO THE PATIENT:

The Momentum Savings Card is not valid for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs (VA), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance, or any State Patient or Pharmaceutical Assistance Program. This offer is void where prohibited by law. Certain rules and restrictions apply.

PLEASE NOTE:

If you need assistance with the Momentum Program, please call 1-855-326-1404. An agent is available to assist you from 8 AM to 8 PM ET, Monday through Friday.

You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.