* = Required Fields
This SAVINGS card can be used to reduce the amount of your out-of-pocket expense up to a maximum of $100 per EpiPen 2-Pak® carton, up to a maximum of three (3) 2-Pak® cartons per prescription. No other purchase is necessary. This offer can be used an unlimited number of times until 12/31/2016. Valid prescription with Prescriber ID# required.
Eligibility Requirements: This SAVINGS card can be redeemed only by patients or patient guardians who are 18 years of age or older who are a resident of the United States and its territories. Not valid for uninsured patients (except for commercially insured patients without coverage for EpiPen® Auto-Injector) 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 EpiPen® Auto-Injector is covered by such government program); if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; or 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 SAVINGS card is not health insurance. The SAVINGS 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. Mylan Specialty reserves the right to amend or end this program at any time without notice. Data related to your redemption with this SAVINGS card may be collected, analyzed and shared with Mylan Specialty for market research and other purposes related to assessing coupon programs. Data shared with Mylan Specialty will be aggregated and de-identified, meaning it will be combined with data related to other EpiPen® SAVINGS card redemptions and will not identify you. The SAVINGS card is not redeemable for cash.
Patient Instructions: Present your SAVINGS card and prescription drug insurance card, along with a valid prescription for the EpiPen 2-Pak® or EpiPen Jr 2-Pak®. By using the EpiPen® 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:
• You have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription.
• Your acceptance of this offer must be consistent with the terms of any drug benefit provided by your health insurer. You agree to report the use of this SAVINGS card to your insurer if required.
Pharmacist Instructions: When you use this SAVINGS card, you are certifying that you have received this SAVINGS card from an eligible patient; you have dispensed the product 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 the terms hereof. 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 SAVINGS card to the patient's insurer if required.
• Submit transaction to McKesson Corporation using BIN #610524
• Primary coverage must exist. Input SAVINGS card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
• Acceptance of this SAVINGS card and your submission of claims for the EpiPen® program are subject to the Mylan Specialty SAVINGS card Terms and Conditions posted at www.epipen.com/copay.
• Acceptance of this SAVINGS card and your submission of claims for the EpiPen® program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.
• For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for EpiPen® program at 800-657-7613 (8:00 AM-8:00 PM EST, Monday-Friday).
EpiPen® (epinephrine injection) 0.3 mg and EpiPen Jr® (epinephrine injection) 0.15 mg Auto-Injectors contain a single dose of epinephrine, which you (or your caregiver or others who may be in a position to administer EpiPen® or EpiPen Jr®) inject into the middle of your outer thigh (upper leg) (through clothing, if necessary). Get emergency medical help right away. You may need further medical attention. Only a healthcare professional should give additional doses of epinephrine if you need more than two injections for a single anaphylactic episode. DO NOT INJECT INTO YOUR VEINS, BUTTOCKS, FINGERS, TOES, HANDS OR FEET. In case of accidental injection, please seek immediate medical treatment. Epinephrine should be used with caution if you have heart disease or are taking certain medicines that can cause heart-related (cardiac) symptoms.
Tell your doctor if you have certain medical conditions such as asthma, depression, thyroid disease, Parkinson's disease, diabetes, high blood pressure or heart disease, have any other medical conditions, are pregnant or plan to become pregnant, or are breastfeeding or plan to breastfeed. Be sure to also tell your doctor all the medicines you take, especially medicines for asthma. If you have certain medical conditions, or take certain medicines, your condition may get worse or you may have longer lasting side effects when you use EpiPen® or EpiPen Jr®.
The most common side effects may include increase in heart rate, stronger or irregular heartbeat, sweating, nausea or vomiting, difficulty breathing, paleness, dizziness, weakness, shakiness, headache, apprehension, nervousness or anxiety. These side effects may go away if you rest. Tell your healthcare professional if you have any side effect that bothers you or that does not go away.Please see the full Prescribing Information and Patient Information.
EpiPen® and EpiPen Jr® Auto-Injectors are for the emergency treatment of life-threatening allergic reactions (anaphylaxis) caused by allergens, exercise, or unknown triggers; and for people who are at increased risk for these reactions. EpiPen® and EpiPen Jr® are intended for immediate administration as emergency supportive therapy only. Seek immediate emergency medical help right away.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
For additional information, please contact us at 800-395-3376.
EpiPen®, EpiPen Jr®, EpiPen 2-Pak®, EpiPen Jr 2-Pak® and My EpiPen® are registered trademarks owned by the Mylan companies. My EpiPen Savings Card™ is a trademark of Mylan Inc. All other trademarks and service marks are the property of their respective owners.
© 2015 Mylan Specialty L.P. All rights reserved. 12/15 EPI-2015-0938