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Eligibility For Patients

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Step 2 in grey color


Required Field
Is the patient a United States Resident?
Does the patient currently have commercial insurance for a portion of the prescription drug cost?
Is the patient enrolled in any federal or state subsidized healthcare program that covers a portion of your prescription drug costs, including Medicare (such as Medicare Part D prescription drug benefit), Medicaid, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs?

*By activating the co-pay card, your patient agrees to the following statements:

  • Your patient’s information above is true and correct
  • Your patient is not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare or Medicaid, or any private indemnity or HMO insurance that reimburses your patient the entire cost of your prescription drug
  • You agree that your patient is not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees
  • Should your patient begin receiving prescription benefits from one of these types of programs at any time, your patient will no longer participate in this savings program.

$0 Co-pay Program TERMS & CONDITIONS

- Patient must meet the eligibility requirements of the $0 Co-pay Program, for example, only commercially insured patients are eligible

- Patient must inform the $0 Co-pay Program of change in insurance status

- It is required that the patient understand, accept, and meet the terms of all the $0 Co-pay Program requirements

- Use of the $0 Co-pay Program must be consistent with and not prohibited by the requirements of the patient’s health insurance

-  The $0 Co-pay Program benefit has a max of $20,000, per brand

- The $0 Co-pay Program is for commercially insured patients using Jivi or KOVALTRY for an approved FDA indication

-  The $0 Co-pay Program does not cover costs for charges associated with patient visits

-  Offer valid only for patients treated in the USA, including Puerto Rico, Guam and US Territories

-  Bayer reserves the right to determine eligibility, monitor participation, equitably distribute product and modify or discontinue the $0 Co-pay Program for Jivi or KOVALTRY at any time with or without notice

-  Patient agrees to provide necessary health information to the administrators of the $0 Co-pay Program

For questions about the $0 Co-pay Program, please call us at 1-647-245-5619.

$0 Co-pay Program for Jivi® and Kovaltry® Co-pay Card