To the Patient: In order to participate in the CRESEMBA Patient Savings Program ("Program"), you must have a valid prescription for CRESEMBA® (isavuconazonium sulfate), meet the eligibility requirements set forth herein and present this card to your pharmacist. You are responsible for the first $25 copay per prescription. The Program has a total maximum savings of $4,000 annually. You are responsible for any remaining balance after all insurance and Program benefits have been applied. The Program expires on 3/31/2019. By participating in this Program, you certify that you meet the eligibility criteria and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the Program should call 1-844-415-0666.
To the Pharmacist: When you use this card, you are certifying:(a) that you have not submitted, and will not submit, a claim for reimbursement under any federal, state, or other government programs for this prescription or where prohibited by law and (b) you will adhere to the terms and conditions stated in the Restrictions section below.
Pharmacist Instructions: First submit claim to the patient's primary third-party payer. Subsequently submit balance due (which includes patient copay amount) to Change Healthcare, as a Secondary Payer COB (coordination of benefits), including a valid Other Coverage Code (e.g., 8). Reimbursement will be received from Change Healthcare. Patient is responsible for any remaining balance after the above benefits have been applied. for any questions regarding online processing, please call Change Healthcare Help Desk at 1-800-422-5604.
Restrictions: This offer is not valid for cash-paying patients. Patient must have prescription drug coverage for CRESEMBA. However, this Program is not valid for patients whose prescription claims are reimbursed, in whole or in part, by any state or federal government program, including, but not limited to, Medicaid, Medicare, Medigap, Department of Defense (DoD), Veterans Affairs(VA), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance, or any State Patient or Pharmaceutical Assistance Program.
This Program is void where prohibited by law. Certain rules and restrictions apply.
This Program is only valid in the United States. Astellas reserves the right to rescind, revoke, or amend this Program without notice at any time.
The Program is managed by PSKW, LLC on behalf of Astellas Pharma US, Inc.
CRESEMBA®, Astellas®, and the flying star logo are registered trademarks of Astellas Pharma Inc.
©2018 Astellas Pharma US, Inc. All rights reserved. 026-0869-PM 12/18