Terms and Conditions
PERTZYE $0 Copay Assistance Program: Available to patients with commercial insurance. Patients pay $0 out-of-pocket costs toward their PERTZYE prescription up to a monthly maximum of $1440. To obtain this benefit, patients must be enrolled in Chiesi CareDirect and utilize one of the network specialty pharmacies. Upon enrollment, the offer is valid for 12 months of copay assistance. Patients with primary enrollment in government-funded plans are not eligible for copay assistance.
PERTZYE $20 Copay Card Program: By signing up for the PERTZYE Co-Pay Card Program, Patient acknowledges that they agree to comply with all the Terms & Conditions listed below. Keep this savings coupon with you for future refills. Please call 1-855-883-1461 if you encounter any issues.
- ELIGIBILITY: Patients are eligible for this offer if: their private insurance co-pay is more than $20; or, they are a cash-paying Patient. Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs, or TriCare, patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees, and Puerto Rico Government Health Insurance Plan. Patients who move from a commercial plan to a government plan will lose eligibility. Must be 18 or older to receive assistance for themselves or a minor. Patients receiving 100% reimbursement from their insurance are not eligible. This offer is not insurance and is restricted to residents of the United States and Puerto Rico. Only good at participating pharmacies. Distribution or use of the Co-Pay Card does not obligate use or continuing use of any specific product or provider.
- PHARMACY: Restat has been authorized to reimburse you per your contracted rate plus the benefit paid with this coupon. This claim may be submitted electronically through Restat using the processing numbers on the front of this card or by mail. Submit all claims in NCPDP Standard D.0. Secondary processing should follow NCPDP standards for Co-Pay Only billing (other coverage code 3, 4, or 8); or by using Coordination of Benefits processing. Mail claims should go to Restat, 11900 W Lake Park Drive, Milwaukee, WI 53224 along with the copy of the pharmacy prescription receipt (cash register receipts are not accepted), and the return address. Retain a copy of this coupon and file with the prescription for auditing purposes. Call the Restat Help Desk at 1-866-450-3277 for processing questions.
360° Debit Card: is available to patients with commercial insurance. Patients must call 1-888-865-1222 to sign up for the 360° Debit Card. For every qualifying monthly prescription of PERTZYE that is filled, the patient can receive $75 to apply toward goods and services including nutritional foods, food services, food preparation tools, vitamins, supplements, probiotics, fitness monitoring devices, pedometers, gym memberships, and expenses related to treatment visits. This offer covers up to $225 for each 3-month supply of PERTZYE. Patients receiving Medicare, Medicaid, or that are participating in any other state or federally subsidized pharmacy benefit program are not eligible for the 360° Debit Card offer. Chiesi reserves the right to rescind, revoke, or amend this offer without notice at any time. This offer is good only in the U.S. The card and offer expire on 12/31/18. Patients participating in the PERTZYE Patient Assistance Program are not eligible.
PAP Eligibility Requirements:
- Legal US resident
- Income level within specified guidelines
- Uninsured or underinsured:
- Commercially insured patients w/o prescription coverage are eligible
- Commercially insured patients with no plan coverage for product are eligible
- Commercially insured patients appealing plan determination are eligible (during the appeal process)
- Patients with a government-funded plan are not eligible for PAP (Medicare Part D, Medicaid, etc.)
- Commercially insured patients with high out-of-pocket costs are not considered eligible. Product is considered covered
To take advantage of these helpful resources, simply work with your doctor to complete and send a Service Request Form to Chiesi CareDirect.