Patients may not seek reimbursement for value received from the Qulipta Complete Savings Card from any third-party payers. Under this program, once an insurer has established a review process for coverage requests, commercially insured patients may receive up to a maximum of 2 one-month fills at no charge for an FDA-approved indication while coverage is pending. Commercially insured patients for whom coverage is not available because the insurer has not established a coverage review process, may be eligible to receive up to 12 one-month fills at no charge. ![]() Subject to all other terms and conditions, a commercially insured patient whose plan covers QULIPTA may receive up to a maximum annual benefit of $7,000 per calendar year, solely for the patient’s benefit, when using the Qulipta Complete Savings Card. Restrictions, including monthly, quarterly, and/or annual maximums, may apply. Patient out-of-pocket expense will vary check with your pharmacist for your co-pay discount. Eligible commercially insured patients may pay as little as $0 per monthly prescription fill. This offer is not valid for cash-paying patients. If at any time, a participating patient begins receiving prescription drug coverage under any federal, state, or government-funded healthcare program, the patient will no longer be eligible for the Qulipta Complete Savings Card and must cease participation. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs) or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. This offer is valid only for patients 18 years of age or older and is good for use only with a valid prescription for QULIPTA® (atogepant) tablets at the time the prescription is filled by the pharmacist and dispensed to the patient. PROGRAM TERMS, CONDITIONS, AND ELIGIBILITY CRITERIA:ġ. ![]() Restrictions, including monthly maximums, may apply. Offer subject to change or discontinuance without notice. Patients may not seek reimbursement for value received from QULIPTA Patient Savings Program, including the copay card, from any third-party payers. Patients residing in or receiving treatment in certain states may not be eligible. ![]() If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use the QULIPTA Patient Savings Program Card and patient must call QULIPTA at 1-800-QULIPTA and stop use of the copay card. Copay assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs) or where prohibited by law or by the patient’s health insurance provider. Eligibility: Available to patients with commercial prescription insurance coverage for QULIPTA who meet eligibility criteria.
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