![]() ![]() IMPORTANT SAFETY INFORMATION WARNING: ANAPHYLAXIS AND INFUSION REACTIONS, G6PD DEFICIENCY ASSOCIATED HEMOLYSIS AND METHEMOGLOBINEMIA You are responsible for reporting the receipt of the co-pay program benefits as required by an insurer, payor, or applicable law or regulation. You may not seek reimbursement from any health savings, flexible savings, or other healthcare reimbursement account for any amounts received from the co-pay program. You may not seek any claims to government payors or other payors or insurers for this prescription. Patients: By enrolling in this co-pay program, you acknowledge and confirm that you and the prescription meet the eligibility requirements set forth in the terms and conditions, including that the prescription will not be reimbursed in whole or in part by any government-funded program (such as, without limitation, Medicare, Medicaid, VA, DOD, TRICARE). Participating Pharmacies or Healthcare Providers: By using this co-pay program, you acknowledge and confirm that the prescription will not be reimbursed in whole or in part by any government-funded program (such as, without limitation, Medicare, Medicaid, VA, DOD, TRICARE) and the patient and prescription meet the eligibility criteria set forth in the terms and conditions. Age for eligibility is dependent on product indication. ![]() This co-pay program is not insurance and is not intended to substitute for insurance. The selling, purchasing, trading, or counterfeiting of any co-pay card or benefits is prohibited by law. Horizon reserves the right to rescind, revoke, or amend offer without notice. Offer not valid where otherwise prohibited by law, for example by applicable state law prohibiting co-pay cards. Offer good only in the United States at participating specialty pharmacies or sites of care. Not valid for prescriptions reimbursed in whole or in part by any government-funded program including but not limited to Medicare, Medicare Part D, Medicaid, Medigap, VA, CHAMPUS, DOD, TRICARE, or any state, patient foundation, or other pharmaceutical program. Terms and Conditions: Offer cannot be combined with any other rebate or coupon, free trial, or similar offer for the specified prescription. The assistance offered under this co-pay program is subject to additional terms and conditions, including but not limited to the following: Patient must be commercially insured and have financial responsibility for a portion of the drug and/or infusion cost if applicable.Patient is a resident of the United States.Patient is prescribed a covered Horizon rare disease medication for an indication approved by the Food and Drug Administration the indication for each product is shown in its prescribing information.Patient’s prescription cannot be paid in part or in full by any government-funded program including but not limited to: Medicare, Medicare Part D, Medicaid, Medigap, VA, CHAMPUS, Department of Defense (DOD), TRICARE, or any state, patient foundation, or other pharmaceutical program. ![]()
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