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This Mylan Patient Savings card can be used to reduce the amount of your out-of-pocket expense up to a maximum of $1,000 per 30-day prescription, after you pay the first $10.00 per 30-day prescription. No other purchase is necessary. This offer can be used up to a total of 12 times per calendar year while this program remains in effect, with a benefit cap of $12,000 per calendar year. Valid prescription with Prescriber ID# required.
Eligibility Requirements: This Mylan Patient Savings card can be redeemed only by patients or patient guardians who are 18 years of age or older and who are residents of the United States and its territories. Patients must have commercial insurance. Not valid for uninsured patients (but may be used by commercially insured patients without coverage for Mylan’s Dalfampridine Extended-Release Tablets) and patients who are covered by any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TriCare (regardless of whether Dalfampridine is covered by such government program); not valid if the patient is Medicare-eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; and not valid if the patient’s insurance plan is paying the entire cost of this prescription. Void outside the US and its territories or where prohibited by law, taxed, or restricted. This program is valid in Massachusetts through June 30, 2019, unless otherwise amended or extended by Massachusetts. This program is not valid in California.
This Mylan Patient Savings card is not health insurance. This card is not transferable and the amount of the benefit cannot exceed the patient’s out-of-pocket expenses. Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. This Mylan Patient Savings card is not redeemable for cash. Mylan Pharmaceuticals reserves the right to amend or end this program at any time without notice.
NOTICE: Data related to your use of this Mylan Patient Savings card may be collected, analyzed and shared with Mylan Pharmaceuticals for market research and other purposes related to assessing coupon programs. Data shared with Mylan Pharmaceuticals will be aggregated and de-identified, meaning it will be combined with data related to other savings card redemptions and will not identify you.
Patient Instructions: By using this Mylan Patient Savings card, you acknowledge that you currently meet the eligibility criteria and that you understand and will comply with the following additional terms and conditions:
Pharmacist Instructions: When you accept this Mylan Patient Savings card, you are certifying that you have received a valid prescription for the applicable product(s) above for an eligible patient; you have dispensed the product(s) as indicated; you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription; and you will otherwise comply with these terms and all applicable terms and conditions. You further certify that your participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that you have as a pharmacy provider, and that you will report the use of this Mylan Patient Savings card to the patient’s insurer if required.