Please answer a few general questions.

You did not answer one or more of the questions. Please review your responses and make corrections where necessary.

The Myrbetriq Savings Program is valid only for residents of the United States or Commonwealth of Puerto Rico. You are not eligible to participate in the program. If you would like to discuss this further, please call 1-855-778-2717.

You are not eligible to participate in this program. Thank you for your interest.

The Myrbetriq Savings Program is not valid for patients covered under Medicaid, Medicare, a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance ("Health Care Reform"), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program. You are not eligible to participate in the Myrbetriq Savings Program. If you would like to discuss this further, please call 1-855-778-2717.

You are not eligible to participate in this program. Thank you for your interest.

Are you a resident of the United States or Puerto Rico?

Which state do you reside in?

Do you participate in any government, state or federally funded medical or prescription benefit programs?
This includes Medicare, Medicaid, Medigap, VA, DOD, and TriCare as well as any other state of federal
employee-benefit programs.

Your card is not valid for prescriptions purchased under Medicaid, Medicare or any other state or federal employee benefit programs. Should you begin receiving prescription benefits from such federal, state or government-funded program at anytime, you will no longer be eligible to participate in the Myrbetriq (mirabegron) Savings Program. We may contact you by phone or mail periodically in order to verify that your eligibility for the program has not changed. Do you acknowledge your agreement with this statement?

If you have insurance and plan to use it together with your Myrbetriq Savings Program Card, please note
that your insurance company will require prior notification. Please indicate you agree to notify
your insurance company if required.

PLEASE NOTE: