Pay as little as $0*

Acthar^® Gel Commercial Co-pay Program Terms & Conditions

This benefit covers Acthar^® Gel (repository corticotropin injection). The Acthar Gel Commercial Co-Pay Program (the "Program") provides up to $15,000 per calendar year toward the patient's Acthar Gel prescription costs.

Eligibility: The Program is available to patients with commercial prescription insurance coverage for Acthar Gel. The Program is not available to patients using a Government-Funded Health Care Program to cover the costs of their prescription or where prohibited by law. The Program cannot be used in whole or part with any government-funded health care program including but not limited to: Medicare (including Medicare Part D and Medicare Advantage), Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs.

The Program may not be available to patients whose commercial insurance plan does not apply Program payments to satisfy the patient's out-of-pocket costs for Acthar Gel, or toward the patient's out-of-pocket maximum. The Program also may not be available to patients who are members of insurance plans that adjust, reduce, or waive their enrollees' out-of-pocket costs based on the availability of, or a member's participation in, manufacturer-sponsored cost-sharing assistance. These programs are often referred to as accumulator adjustment or maximizer programs. Patients with these plan terms may not be eligible to use the Program but may be eligible for other needs-based assistance provided by Mallinckrodt. If you believe your commercial insurance plan may have such terms, please contact Acthar Patient Support at 1-888-435-2284.

Participating patients are responsible for providing Mallinckrodt with accurate information necessary to determine Program eligibility. If at any time a patient decides to use any government-funded health care program to cover the cost of their prescription, the patient will no longer be able to use the Program and the patient must call Acthar Patient Support at 1-888-435-2284 to stop participation. Participating patients are solely responsible for notifying Mallinckrodt of changes to their prescription health insurance, including, but not limited to, utilization of a government-funded health care program for Acthar coverage, or the addition of any terms under which Program benefits are not applied or credited to a patient's out-of-pocket costs or maximum, such as an accumulator adjustment program or a maximizer program.

Health plans, employers, specialty pharmacies, pharmacy benefit managers, and vendors or agents of any of the foregoing (individually and collectively, "Plan Agents") are prohibited from enrolling patients in the Program or assisting patients with enrollment in the Program. The patient, or a legal representative of the patient who is not a Plan Agent, must personally enroll the patient in the Program for the patient to be eligible for Program benefits.

The value of this Program is exclusively for the benefit of patients and is intended to be credited solely toward patient out-of-pocket costs, including applicable co-payments, coinsurance, and deductibles. Patients are responsible for costs not covered by the Program, including costs in excess of the Program's annual maximum benefit.

Mallinckrodt, in its sole discretion, may reduce, eliminate, or amend Program benefits, eligibility, terms or conditions for any patient at any time without notice, including, but not limited to, where the plan or Plan Agent imposes conditions or requirements on a patient's ability to receive funding under the Program, requires patient enrollment in the Program as a condition of participation in any plan or plan benefit, coverage, or program, or otherwise acts in a manner that materially affects these Terms and Conditions.

Patients may not seek reimbursement from any third-party payers for value received from the Program.

The Program does not constitute prescription drug coverage and is not intended as a substitute for health insurance. The Program is not available where prohibited by law. Other restrictions may apply. Program terms, conditions, and benefits are subject to change or discontinuance without notice.