Co-Pay Terms and Conditions

Eligibility Criteria

The benefit available under the co-pay assistance program is limited to the amount that the eligible patient’s private health insurance company indicates that the patient is obligated to pay for the Covered Drug, up to an annual maximum. For patients covered by commercial benefit plans, the Co-Pay Assistance Program discount per syringe is capped at Fifteen Hundred Dollars ($1,500.00) and the patient is capped at Fifteen Thousand Dollars ($15,000.00) per calendar year (January 1 through December 31). For non-insured/cash paying patients, the co-pay assistance program offers a per-Covered Drug purchase discount of One Hundred Fifty Dollars ($150.00) discount off the total cash price for an individual syringe and a discount of Four Hundred Fifty Dollars ($450.00) for the syringe three (3) pack.

Offer void where prohibited. Patients who are uninsured are eligible for the Co-pay Assistance Program. The Co-pay Assistance Program is not valid for patients covered under Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange [marketplace] established by a state government or the federal government), Medicare, a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered) a Medigap plan, an employer-sponsored health plan or prescription drug benefit program for Medicare-eligible retirees, VA, TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan (“Healthcare Reform”), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program (collectively, “Government Programs”). If you live in Massachusetts, the Card expires on the earlier of: (i) the expiration date of this card 12/31/2021; (ii) the date an AB-rated generic equivalent becomes available; or (iii) January 31, 2021 absent a change in Massachusetts state law. If you live in California, the card expires on the earlier of: (i) the expiration date of this card 12/31/2021 or (ii) the date an FDA approved therapeutically equivalent for Icatibant or over the counter product with the same active ingredients becomes available. Available only in the U.S. and Puerto Rico for residents of the U.S. and Puerto Rico.

By accepting this offer, you agree that if you are required to do so under the terms of your insurance coverage for this prescription or are otherwise required to do so by law, you should notify your insurance carrier of your redemption of this Card. This offer is not valid with any other program, discount, incentive, or similar offer involving Icatibant. It is prohibited for any person to sell, purchase, or trade; or to offer to sell, purchase or trade; or to counterfeit this Card. This offer may be terminated, rescinded, revoked or amended by Fresenius Kabi, LLC, at any time without notice. This Card is not health insurance. This Card expires on 12/31/2021.

For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for KabiCare at 833-522-4227 (8:00 AM-8:00 PM EST, Monday-Friday).

Acceptance of this card and your submission of claims for the Icatibant Injection are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.