![]() By using this offer, you authorize the Program Administrator to share your prescription information with CoverMyMeds so that CoverMyMeds may contact your healthcare provider to request submission of information to support coverage of your LYBALVI prescription by your health insurance plan. This information is needed for the Program Administrator, and its service providers to enroll the patient in the LYBALVI Co-pay Savings Program. Use and Disclosure of Information: Before the LYBALVI Co-pay Savings Card is activated, the patient will be asked to provide personal information that may include their name, date of birth, type of insurance, and contact information. Program Administrator or its designee will have the right upon reasonable prior written notice, during normal business hours, and subject to applicable law, to audit compliance with this Program. Void where prohibited by law, taxed or otherwise restricted. This Program offer is limited to one per patient and may not be used with any other coupon, discount, prescription savings card, free trial, or other offer and is not transferable, and may not be sold, purchased or traded, or offered for sale, purchase, or trade. Alkermes may rescind, revoke, or amend this Program, eligibility, benefits, and requirements at any time without notice, including in specific states. Program may be subject to plan benefit design requirements. To use this Program, participating patients are responsible for following any health plan requirements, including any requirements to inform the health plan how much co-payment support they get from this Program. The LYBALVI Co-pay Savings Card expires after 5 years but may be renewed if all eligibility criteria are met.Īdditional Terms of Use: This Program offer is not conditioned on any past, present, or future purchase, including refills. All Program payments are for the benefit of the patient only. Eligible patients may receive benefits for valid claims submitted with a date of service that is up to 90 days prior to the initial enrollment date. Beginning at fill 4 and thereafter, a maximum savings of $450 per 30-day supply will be provided towards the cost of the LYBALVI prescription. Maximum 30-day supply per fill for the first 3 fills in the Program. Program Benefit: Maximum savings limit applies patients’ out-of-pocket expenses may vary. ![]() Patients must meet the Program requirements every time they use the LYBALVI Co-pay Savings Card. Patients must live in the United States or Puerto Rico. Program is not valid for cash paying patients. Patients who become eligible for any government program that pays for any portion of medication costs will no longer be eligible for this Program. This Program is not available to patients who are enrolled in, or covered by, any local, state, federal or other government program that pays for any portion of medication costs, including but not limited to Medicare, including Medicare Part D or Medicare Advantage plans Medicaid, including Medicaid Managed Care and Alternative Benefit Plans under the Affordable Care Act Medigap VA DOD TRICARE or a residential correctional program. Health plan requirements for a prior authorization and/or step therapies must be attempted, and an outcome documented, regardless of the outcome, prior to using this co-pay offer. ICD-10-CM=International Classification of Diseases, Tenth Revision, Clinical Modification.Įligibility for LYBALVI ® Co-pay Savings Program (Program): This Program is only available to commercially insured patients who are 18 years or older with a valid LYBALVI prescription. Under no circumstances will Alkermes, Inc., or its affiliates, employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages that may arise from, or be incurred in connection with, the information provided here or any use thereof. Additional insurance requirements may apply and healthcare providers should always contact the insurer directly to obtain complete and current information regarding coverage of LYBALVI.Īlkermes does not guarantee coverage or reimbursement. Healthcare providers also are responsible for the accuracy of all claims and related documentation submitted for reimbursement. IMPORTANT: Healthcare providers are responsible for keeping current and complying with all applicable coverage requirements and for the selection of diagnosis and procedure codes that accurately reflect their patient’s condition and the services rendered. Bipolar disorder, in full remission, most recent episode mixed
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