Welcome 8237

Please answer the question(s) highlighted in red.

What type of prescription insurance coverage does the patient have?

Any government, state or federally funded prescription benefit program. This includes Medicare, Medicaid, Medigap, VA, DOD and Tricare.

Commercially insured (private insurance).

Do not have prescription drug coverage - paying cash.

By submitting this form, I understand that my personal information provided and information pertaining to use of the coupon at the pharmacy will be shared with Xcovery Holdings, Inc., its third-party partners and McKesson entities.
I also authorize Xcovery Holdings Inc., its partners and McKesson entities to communicate with me about products, health conditions, co-pay and financial assistance. I agree to be contacted by mail, email, and at the phone number provided to leave voice messages, and interactive voice recordings. I may opt out of individual communications of the program entirely at any time by calling (888) 215-8384, or by clicking on the "unsubscribe" link. Xcovery Holdings, Inc. and companies providing services to Xcovery Holdings, Inc. will not sell or rent personally identifiable information, as described in the Privacy Policy, which can be viewed by visiting www.ensacove.com.

Yes

Please confirm patient eligibility: