Saving Card

By using the PIVYA® (Pivmecillinam tablets) Savings Program, you confirm that you understand and agree to comply with the following Terms and Conditions:

• Must be 18 years of age or older to redeem this copay card.
• This copay card is only valid for eligible patients with private/commercial insurance and Not Covered Patients. “Not Covered Patients” are defined as those patients who have private/commercial insurance, but the drug is not covered on the plan’s formulary or has an NDC block, prior authorization, step edit, or other restriction that has not been met.
• This copay card is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.
• Reimbursement limitations apply. Patient is responsible for all additional costs and expenses after reimbursement limits are reached, including additional copayment and coinsurance amounts.
• Patients with high deductible or coinsurance health plans may pay more than $0. For questions, please call (312) 395-7386
• For private/commercial insurance but Not Covered Patients using Other Coverage Code (OCC) 03, this copay card may not be redeemed by Not Covered Patients more than once per 25 days per patient.
• This copay card shall be applied only toward the cost of an eligible prescription product and not toward ancillary services or treatment costs.
• This copay card is good for use only with the products identified herein. No other purchase is necessary.
• You agree not to seek reimbursement for all or any part of the benefit received through this copay card and are responsible for making any required reports of your use of this program to any insurer or other third party who pays any part of the prescription filled.
• This copay card is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private/ commercial insurance plan or other private/commercial health or pharmacy benefit programs.
• This copay card is only good in the United States of America (including the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands).
• This copay card is not valid where prohibited, taxed, or otherwise restricted.
• You must present this copay card along with your prescription to participate in this program.
• The copay card cannot be redeemed at government-subsidized clinics.
• This copay card is not health insurance.
• The selling, purchasing, trading, or counterfeiting of this copay card is prohibited by law. Void if reproduced.
• This copay card is not valid with other savings offers. This copay card has no cash value. This copay card is not transferable.
• Alembic Therapeutics reserves the right to rescind, revoke, terminate, or amend this copay card at any time without notice.
• When you use this copay card, you are certifying that you understand and agree to comply with the program rules, regulations, eligibility requirements, and Terms and Conditions.
• For questions call: (312) 395-7386