Welcome to the Sprout Access Activation Site
This program is only available to residents of the United States and US territories, where specified. Most commercially insured and eligible uninsured patients are eligible. This offer is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, TRICARE, the Veterans Administration, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare programs. If your insurance changes, you may no longer be eligible to use this coupon. Coupons can only be processed exclusively at participating pharmacies.
To activate your coupon, please answer the following questions:
  • Patient First Name:

  • Patient Last Name:

  • Address 1:

  • Address 2:

  • City:

  • State:

  • E-Mail Address:

  • Phone Number:

  • Preferred Method of Contact:

  • Please enter the date of birth of the patient who will use this coupon.

  • Please enter the 5 digit zip code of the residence of the patient who will use this coupon.

  • Are prescriptions of the patient who will use this coupon paid in part or in full under any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance plan or any other federal or state healthcare programs?

  • Does the patient who will use this coupon have commercial (in part or in whole) prescription coverage?

  • Please confirm that, by activating this coupon, you have read, understand and will comply with the terms and conditions of the program and that you currently meet all eligibility criteria.

  • You understand that the personal information you provide and information pertaining to the use of your coupon at the pharmacy will be shared with Sprout Pharmaceuticals, and third parties working with (or for) Sprout Pharmaceuticals. You also authorize Sprout Pharmaceuticals, and companies working with or for it, to communicate with you by email, phone or text message at the number I have provided about products, including marketing materials, health conditions, co-pay and financial assistance. You agree to be contacted by mail, email, and/or at the phone number you provide. You may opt out of individual communications entirely at any time by calling 855-280-0581.
    Sprout Pharmaceuticals and companies providing services to Sprout Pharmaceuticals will not sell or rent your personally identifiable information, as described in the Privacy Policy, which you can view by visiting Sprout Pharma Privacy Policy.

Eligibility Criteria/Terms and Conditions:

By using the coupon, you confirm that you understand and agree to comply with the following terms and conditions of this offer: