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US.GLT.16.11.136 Co pay Information Sheet .pdf


Original filename: US.GLT.16.11.136_Co-pay Information Sheet.pdf

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SANOFI GOES ALL IN-SULIN

Lantus® pen and vial and Toujeo ® pen are included.

NEW 10 COPAY
$

*

SAVINGS OFFER FOR ELIGIBLE* PATIENTS WITH A VALID PRESCRIPTION FOR:

© 2002-2017 sanofi-aventis U.S. LLC. All rights reserved. US.GLT.16.10.150

• Submit transaction to McKesson Specialty Arizona, Inc. using BIN #610524.
• If primary coverage exists, input 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 card and your submission of claims for the Sanofi US Corporate Loyalty Card Program are subject to the
LoyaltyScript® program Terms and Conditions established by McKesson Specialty Arizona, Inc. By accepting this card, you agree to
the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.
• LoyaltyScript® is not an insurance card.
• For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript®
for Sanofi US Corporate Loyalty Card Program at 866-390-5622 (8:00 AM-8:00 PM EST, Monday-Friday).

SUBJECT TO MAXIMUM SAVINGS
FOR TOUJEO® OR LANTUS® FOR 12 MONTHS

• Maximum of 3 boxes of Toujeo SoloStar® per prescription.
• If you are enrolled in a commercial insurance plan: Maximum savings of up
to $500 per box.
• Not enrolled in a commercial insurance plan: Maximum savings of up to
$200 per box.
• Maximum of 3 boxes of Lantus SoloStar® or 3 vials of Lantus® per prescription.
• If you are enrolled in a commercial insurance plan: Maximum savings of up
to $500 per box of Lantus Solostar® or vial of Lantus®.
• Not enrolled in a commercial insurance plan: Maximum savings of up to $100
per box of Lantus Solostar® or vial of Lantus®.

Pharmacist: When you process this card, you are certifying that you have read, understood, and are in compliance with the terms
and conditions pertaining to this program. You are further certifying that you have not submitted and will not submit a claim for
reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including any state pharmaceutical
assistance program for this prescription.

You pay $10 for Toujeo® or Lantus ® whether they
are covered by your insurance or not.

• If you are enrolled in a commercial insurance plan or paying cash: Maximum
savings of $100 off per monthly prescription of Apidra SoloStar® or vial of Apidra®.

*See back of the card. Sanofi US reserves the right to rescind, revoke, or amend any and all offers without notice.

Patient Instructions: If prescription is covered by insurance, you may need to notify the insurance carrier of redemption of this
copay card. This offer is not valid for prescriptions covered by or submitted for reimbursement under Medicaid, Medicare, VA,
DOD, TRICARE, or similar federal or state programs including any state pharmaceutical assistance program. This program is not
valid where prohibited by law. By redeeming this coupon, you are certifying that (1) you are not a beneficiary of any government
funded programs as noted above; (2) should you begin receiving prescription benefits from any government funded program,
you will withdraw from this savings program; and (3) you acknowledge and understand that adherence to the terms and
conditions of this offer, as noted above and posted at www.mckesson.com/mprstnc, is necessary to ensure compliance with
laws pertaining to Federal Healthcare Programs. For questions regarding your eligibility or benefits, or if you wish to discontinue
your participation, call the Sanofi US Corporate Loyalty Card program at 866-390-5622 (8:00 AM-8:00 PM EST, Monday-Friday).

FOLD

RX SAVINGS PROGRAM

10*

$

PER PRESCRIPTION
Subject to Maximum Savings (See Inside)
RxBIN: 610524
RxPCN: Loyalty
RxGRP: 50777058
ISSUER: (80840)
ID: XXXXXXXXX

THIS CARD CAN BE USED IN ANY RETAIL PHARMACY.
FOR MAIL ORDER PHARMACY, ACTIVATE YOUR CARD THEN FOLLOW THESE STEPS:

1. Call your mail order pharmacy
to seelantus.com
if they accept the Sanofi Rx Savings Card.
Go to toujeo.com
or
or call 866-390-5622
2. If your mail order pharmacy DOES accept the Sanofi Rx Savings Card:
to get or activate
Sanofi
Rxwith Savings
Card.
Mail a copy of your card toa
the pharmacy
or provide them
the RxBIN, RxGRP, RxPCN, and
your
Sanofi Rx Savings Card ID number on the front of your card to be applied to your prescription.

Offer valid in3.retail
If your mailpharmacies
order pharmacy DOES NOTnationwide.
accept the Sanofi Rx Savings Card, you can go to your local

OPEN FOR SAVINGS
AND TERMS OF USE
INFORMATION

*Savings may vary. See inside and reverse for eligibility and terms of use.
Apidra® $0 Co-Pay Offer Continues:

Eligible patients pay $0 for Apidra® SoloStar® or vial.
Subject to terms of use inside and on reverse of card.

pharmacy and use the card immediately; or
Fill the prescription at your mail order pharmacy and apply for a rebate as follows:
a) Go to www.patientrebateoneline.com or call 1-866-390-5622 to request a Direct Member
Reimbursement (DMR) form.
b) Return the completed DMR form, along with your pharmacy receipt, to the address on the form.
c) If eligible, you should receive a rebate check within 2-4 weeks of eligibility verification.

RX SAVINGS PROGRAM

*OFFER DETAILS:
3.375”w

T his offer is not valid for prescriptions covered by or submitted for reimbursement under Medicare, Medicaid, VA, DOD, TRICARE,
or similar federal or state programs, including any state pharmaceutical programs. Void where prohibited by law.
For the duration of the program, the Savings Card carries maximum savings up to:
• $500 per pack for all patients who are enrolled in a commercial insurance plan, whether Toujeo ® or Lantus ® is covered or
not by your insurance
• $200 per pack of Toujeo ® for patients not enrolled in a commercial insurance plan
• $100 per pack of Lantus ® for patients not enrolled in a commercial insurance plan
This offer is valid for up to 3 packs per prescription.
Savings may vary depending on patients’ out-of-pocket costs. Upon registration, patients receive all program details.
Sanofi US reserves the right to change the maximum cap amount, rescind, revoke, or amend the program without notice.

© 2002-2016 sanofi-aventis U.S. LLC.
All rights reserved.

US.GLT.16.11.136


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