![]() ![]() Click to learn about eligible medicines and their yearly coverage amounts. By participating in the Program, participants acknowledge that they understand and agree to comply with the complete terms and conditions, available at /copay. Eligible patients may pay as little as 0 co-pay per fill on select prescribed ViiV Healthcare medications. Alexion reserves the right to rescind, revoke, or amend this program without notice. Compare prices for Tivicay and download your savings card instantly to save up to 80. Patients residing in Massachusetts, Minnesota, and Rhode Island are eligible for assistance with medication costs but are not eligible for assistance with infusion costs. The Inside Rx Tivicay savings card works just like a manufacturer coupon to save on the cost of Tivicay. This offer cannot be combined with any other rebate/coupon, free trial, or similar offer. No claim for reimbursement of any out-of-pocket expense amount covered by the Program may be submitted to any third-party payer, whether public or private. The Program is not valid for costs eligible to be reimbursed, in whole or in part, by Medicaid, Medicare (including Medicare Part D), Medicare Advantage Plans, Medigap, Veterans Affairs, Department of Defense or TRICARE, or other federal or state programs (including any state prescription drug assistance programs). IMPORTANT NOTICE: The Alexion OneSource™ Copay Program (“the Program”) pays for eligible out-of-pocket medication and infusion costs associated with SOLIRIS ® (eculizumab) up to $15,000 US dollars per calendar year. Reside in the United States or its territories. ![]() ![]() Be prescribed SOLIRIS for an FDA-approved indication by a US-licensed physician.Patients can apply for the CoPay Program by filling out the enrollment form at /copay. Get immediate assistance from a ViiV Healthcare Professional. Copy or picture of the prescription medication label, including: date of fill, name of. Tivicay / Tivicay PD Juluca Rukobia Triumeq / Triumeq PD Vocabria Combivir. Copy of the front and back of your insurance card. Mail the form via the Postal Service with the following documents: Copy of your ViiV Healthcare prescription medication receipt. The Alexion OneSource CoPay Program may help patients pay for eligible out-of-pocket medication and infusion costs. You can print the form and fill it out by hand. ![]()
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