Octreotide_Copay

Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Card

Savings Card Terms and Conditions

With this Savings Card, you may pay as little as $0 for each fill of Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, while this program remains in effect. This Savings Card may be used to reduce the amount of your out-of-pocket costs for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use up to an aggregate maximum of $10,000 per calendar year, while this program remains in effect. No other purchase is necessary. Valid prescription with Prescriber ID# is required. Mylan Institutional Inc., a Viatris Company, reserves the right to amend or end this program at any time without notice.

Eligibility Requirements: This Savings Card may 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 with coverage for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use. This program is not valid for uninsured patients or commercially insured patients without coverage for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use; not valid for 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 Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use 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. This program is void outside the U.S. and its territories or where prohibited by law, taxed, or restricted, and may not be available in all states.

This Savings Card is not health insurance. This Savings Card is not transferable, and the amount of the savings cannot exceed the patient’s out-of-pocket costs. This Savings Card cannot be combined with any other rebate/coupon, cash discount card, free trial, or other offer for the specified prescription. This Savings Card is not redeemable for cash. This Savings Card is not valid for product dispensed by a 340B covered entity that purchased the product at discounted pricing under the 340B drug pricing program. This Savings Card is not valid if the patient’s commercial health insurance plan or pharmacy benefit manager uses a copay adjustment program (often termed “maximizer” or “accumulator” program) that restricts any form of copay assistance from being counted toward the patient’s cost-sharing limits.

NOTICE: Data related to your use of this Savings Card may be collected, analyzed, and shared with Mylan Institutional Inc., a Viatris Company, for market research and other purposes related to assessing its savings card programs. Data shared with Mylan Institutional Inc., a Viatris Company, will be aggregated and de-identified, meaning it will be combined with data related to other savings card redemptions and will not identify you.

Medical Claims:
  • Eligible patients must have an out-of-pocket cost for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use and be administered the product while this program remains in effect. The benefit available under this Savings Card is valid for the eligible patient’s out-of-pocket cost for the product only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges, evaluations, or diagnostic testing) even if such costs are associated with the administration of Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use.
  • A provider is required to submit a copy of the Explanation of Benefits (EOB) from their commercial insurance plan detailing the patient’s out-of-pocket costs for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, and a copy of the insurance claim form (CMS-1500, UB04, or electronic equivalent) to receive reimbursement from Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Card program. All claims must be submitted within 180 days of the EOB date.
  • This Savings Card may apply to eligible out-of-pocket costs incurred by the patient for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, up to 180 days prior to the date an eligible patient is enrolled in this program, subject to annual program maximum and the applicable Terms and Conditions based on Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use administration date. Patient or provider may contact Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Card program at 1-833-378-3692 for more information.

Valid only for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, National Drug Codes: 67457-756-10, 67457-759-20, 67457-762-30

Patient Instructions: By using this Savings Card, you hereby accept and agree to abide by these terms and conditions. Further, you acknowledge and agree that you currently meet the eligibility criteria and other requirements described herein every time you use this Savings Card 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 use of this Savings Card must be consistent with the terms of any drug benefit provided by your commercial health insurer, health plan, or private third-party payer. You agree to report the use of this Savings Card to your commercial insurer, if required.
  • Where required, a Savings Card and primary prescription drug insurance card, along with a valid prescription for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, must be presented to participate in this program.
  • Should you begin receiving prescription benefits from any government funded program, you will withdraw from this Savings Card program.

Pharmacist Instructions: When you accept this Savings Card, you are certifying that you have received this Savings Card from an eligible patient; you have received a valid prescription for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use for 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 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 Savings Card to the patient’s insurer, if required.

  • Submit transaction to Mercalis using BIN # 610020.
  • For commercially insured patients, input this Savings Card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable patient savings will be displayed in the transaction response. Cash Discount Cards are not valid as primary insurance under this offer.
  • Acceptance of this Savings Card and your submission of claims for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Card program are subject to the Savings Card Terms and Conditions posted at www.viatrisoctreotidesavingsoffer.com.
  • Reimbursement will be received from Mercalis. For questions regarding setup, pharmacy claims submission, patient eligibility, or other issues, call the Help Desk for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Card program at 1-844-586-7922.

Prescriber Instructions: By using this Savings Card, you are certifying that you have received this Savings Card from an eligible patient; 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. All claim submissions must include a copy of the Explanation of Benefits and a copy of the insurance claim form (CMS-1500, UB04, or electronic equivalent). Medical claims may be submitted by one of the below methods:

  • Fax: 1-833-590-3770.
  • Mail to: Octreotide Savings Offer Program, 2250 Perimeter Park Dr., Suite 300, Morrisville, NC 27560.
  • Reimbursement will be received from Mercalis. For questions regarding setup, medical claims submission, patient eligibility, or other issues, call the Help Desk for Viatris’ Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Card program at 1-833-378-3692.