[Pay as little as $0*] for Teva's generic version of Firazyr® (icatibant injection)
*Commercially insured patients may [pay as little as $0 out of pocket] for Teva’s Icatibant Injection. This offer is not available to non-insured/cash-paying patients nor to patients eligible for prescription coverage by any state or federally funded healthcare programs. Please see full Terms and Conditions below.
By accepting the offer, I confirm that I do not have Medicare, Medicaid, or other public payer coverage and I am eligible for this offer in accordance with the Terms and Conditions.
How to use your Teva savings card:
- Download the digital savings card and present it at your pharmacy
- Ask your pharmacist to fill your existing prescription with Teva’s Icatibant Injection
Savings Offer Terms and Conditions
Terms and Conditions: Patients are not eligible if prescriptions are paid for in part or full by any state or federally funded programs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, TRICARE, or by private health benefit programs which reimburse for the entire cost of prescription drugs. This card is not valid for patients who are Medicare eligible and are enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., patients who are eligible for Medicare Part D but who receive a prescription drug benefit through a former employer). Cash Discount Cards and other non-insurance plans are not valid as primary under this offer. If the patient is eligible for drug benefits under any such program, the patient cannot use this offer. By redeeming this offer, the patient and the pharmacist acknowledge that the patient is eligible, and the patient and the pharmacist understand and agree to comply with the Terms and Conditions of this offer.
Void if copied, transferred, purchased, altered or traded and where prohibited and restricted by law. This is not an insurance program. This offer may not be used with any other discount, coupon or offer. This offer expires on [12/31/2022]. This program is managed by [TrialCard] on behalf of Teva Pharmaceuticals USA, Inc. Teva reserves the right to limit, change or discontinue this offer at any time without notice. If you have any questions regarding your eligibility or benefits, please call [844-248-7949].
Valid only for Teva’s Icatibant Injection, National Drug Code #00093-3066-34 and 00093-3066-93
To the Patient: This offer is for eligible Commercially Insured Patients only. Patients may [pay as little as $0 out of pocket] for Teva’s Icatibant Injection. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. Patient is responsible for costs above maximum benefit amounts. This offer must be presented along with your prescription for Icatibant Injection and your primary insurance card to participate in this program. Offer not valid for Non-Insured/Cash-Paying patients or where Icatibant Injection is not covered by the primary insurance.
To the Pharmacist: By redeeming this offer, the Pharmacist certifies that Teva’s Icatibant Injection is being dispensed to a patient eligible for this offer in compliance with these Terms and Conditions and the Pharmacy has not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. For Commercially-Insured Patients, please submit this claim to the primary Third-Party Payer first, then submit the balance due to [TrialCard] as a Secondary Payer COB (coordination of benefits) with patient responsibility and a valid Other Coverage Code (e.g. 8). Reimbursement will be received from [TrialCard]. For questions about processing, please call [844-248-7949].
© 2022 Teva Pharmaceuticals USA, Inc. TG-42931 January 2022
Firazyr® is a trademark of Shire Orphan Therapies, GmbH.