Welcome to the Medicare Part D Alternative Coupon Program
If you are enrolled in Medicare Part D and your drug insurance does not cover Bijuva®, or your out-of-pocket cost under your insurance exceeds $50 for a 30-count supply, $100 for a 60-count supply, or $150 for a 90-count supply, Mayne Pharma may be able to help.
The Bijuva® Medicare Part D Alternative Coupon Program, sponsored by Mayne Pharma, provides you with the choice to opt-out of using your Medicare Part D prescription plan for your Bijuva® prescription benefit and activate this offer to reduce your out-of-pocket expense.
To initiate this offer, you must complete the form below to confirm that you meet certain terms and conditions and you must opt-out of your Medicare Part D prescription benefits for Bijuva®.
*Terms, conditions, and limitations apply. Please see below for the program's eligibility requirements and terms and conditions.
ELIGIBILITY CRITERIA/TERMS AND CONDITIONS:
- Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the Bijuva® Medicare Part D Alternative Coupon Program must agree to the following terms and conditions:
- Patients must present a valid prescription for Bijuva® to a participating retail pharmacy with the coupon provided to receive a cost reduction on their out-of-pocket expense.
- Patients understand that the Bijuva® Medicare Part D Alternative Coupon Program is valid until the end of the calendar year of which enrollment was approved.
- Patients understand use of the coupon is limited to prescriptions filled from the date enrollment is approved through the end of the calendar year of which enrollment was approved.
- Patients are responsible for all additional costs and expenses after reimbursement limits are reached. Maximum limits apply.
- Patients must have prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
- Patients agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for Bijuva® purchased with the coupon for the current calendar year.
- Patients must notify their prescription plan that Bijuva® has been purchased outside of benefit by sending the Opt Out Letter provided by Mayne Pharma.
- Patients with commercial/private insurance, uninsured patients, or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE are not eligible to participate in the Bijuva® Medicare Part D Alternative Coupon Program.
- No other purchase necessary.
- This Bijuva® Medicare Part D Alternative Coupon Program can be used by eligible patients residing in the United States (including Puerto Rico, Guam and the US Virgin Islands) at participating retail pharmacies in the United States. Product must originate from the United States.
- The Bijuva® Medicare Part D Alternative Coupon Program card is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer not already associated with this offer.
- Medicare Part D Alternative Coupon Program card is not insurance.
- Mayne Pharma reserves the right to rescind, revoke, or amend this offer at any time without notice.
- It is illegal to sell, purchase, trade, or counterfeit, the Bijuva® Medicare Part D Alternative Coupon Program offer or card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
De-identified patient data related to your redemption of the Bijuva® Medicare Part D Alternative Coupon Program may be collected, analyzed, and shared with Mayne Pharma, for market research and other purposes related to assessing patient savings programs. The patient understands they are consenting to allow Mayne Pharma and its contracted vendor InfinityRx (InfinityRx Privacy Policy) to store all collected personal and medical information for the administration of this program. For questions call: 888-927-3499. The healthcare information contained herein is not intended to replace discussion with your healthcare provider. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient.