Enroll Eligibility 7378

Helping Patients Access Quality Brands

Sun Pharma Copay Program

Welcome to the Sun Pharma Copay Program activation site. Please provide the following information to activate your copay card and begin saving.

Card ID (Please leave blank if you do not have a card)
First Name*	Last Name*
Address - Line 1	Address - Line 2
City	State	Zip Code*
Date of Birth*	Patient's 10‑Digit Phone Number*
E-mail Address	Preferred Method of Contact:
Are you enrolled in any government, state of federally funded medical or prescription benefit program, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, and Tricare?*
Yes No
Do you have commercial insurance coverage?*
Yes No
You understand that the personal information you provide and information pertaining to the use of your copay card at the pharmacy will be shared with Sun Pharma, and its third party partners. Sun Pharma and companies providing services to Sun Pharma will not sell or rent your personally identifiable information, as described in the Privacy Policy, which you can view by visiting https://sunpharma.com/usa/privacy-policy.*
Yes No
You agree to be contacted at the phone number, address or email provided to receive information about products, services and promotional offers from Sun Pharma. You understand that you have the ability to opt-out of these by calling 855‑820‑9077.*
Yes No
*Field is required.

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