DETERMINE ELIGIBILITYIS THE FOCALIN XR® CO-PAY CARD* RIGHT FOR YOU?

To find out if you are eligible for the FOCALIN XR Co-Pay Card, simply answer the questions below. Please note that this information must be entered by you or a caregiver, and cannot be entered by a third party.

focalin savings card
*
Limitations apply. Reimbursement limited to $60 for a 30-day supply. See program terms and conditions below. This offer is not valid for residents of Massachusetts or under Medicare, Medicaid, or any other federal or state program. Novartis reserves the right to rescind, revoke, or amend this program without notice.

1.

I certify that I am over the age of 18 and that I am the patient or that I am the patient's caregiver and have the patient's consent to proceed with the enrollment of the FOCALIN XR Co-Pay Card.

YES

NO

You must be 18 years or older to complete this enrollment form. Please have a parent or caregiver who is at least 18 years of age complete the enrollment process or call 1-866-877-4633.

2.

Do you have commercial (also known as private) insurance?

YES

NO

Patient IneligibleIt doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as it's only valid for those with commercial insurance. Please call 1-800-245-5356 to find out if there are other forms of support for you. Learn more.

3.

Are you a resident of Massachusetts?

YES

NO

Patient IneligibleIt doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as the offer is not valid for Massachusetts residents. Please call 1-800-245-5356 to find out if there are other forms of support for you. Learn more.

4.

Are you enrolled in any state or federally funded programs, including but not limited to Medicare, Medicaid, VA, DoD, or Tricare?

YES

NO

Patient IneligibleIt doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as the offer is not valid under Medicare, Medicaid, or any other federal or state program. Please call 1-800-245-5356 to find out if there are other forms of support for you. Learn more.

5.

Are you paying cash for the full price of the prescription?

YES

NO

Patient IneligibleIt doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as the offer is not valid for cash-paying patients. Please call 1-800-245-5356 to find out if there are other forms of support for you. Learn more.

*Terms and conditions

Valid only for those with commercial insurance. Patient pays the first $10 of co-pay. Novartis pays up to the next $60 per 30-day supply. Patient pays any remaining co-pay amount. The Novartis co-pay support of $60 per month is not to exceed an annual maximum of $720. This offer is not valid under Medicare, Medicaid or any other federal or state program, for residents of Massachusetts, for cash-paying patients, where product is not covered by patient's commercial insurance, or where plan reimburses you for entire cost of your prescription drug. Offer is not valid where prohibited by law. Valid only in the United States and Puerto Rico. This program is not health insurance. Offer may not be combined with any other rebate, coupon, or offer. This card is the property of Novartis Pharmaceuticals Corporation and must be returned upon request. Novartis reserves the right to rescind, revoke, or amend the program without notice. Patient certifies responsibility for complying with applicable limitations, if any, of any commercial insurance and reporting receipt of program rewards, if necessary, to any commercial insurer. This offer expires on December 31, 2017.

isi Patient Product Information Prescribing Information www.fda.gov/medwatch