Responses to all questions are required.

  • Is the person who will use this Co-Pay Card enrolled in any state- or federally-funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD or TriCare?

  • Please enter the 5-digit ZIP code of the person who will use this Co-Pay Card.

  • Do you have an actual Qudexy® XR Co-Pay Card?

  • Please enter the 10-digit Member ID number from the Co-Pay Card received.

  • Please enter the 8-digit RxGroup number from the Co-Pay Card received.




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