PHARMACIST: Process a Coordination of Benefits (COB/split bill) claim using the patient’s prescription insurance for the PRIMARY claim. Submit a SECONDARY claim to CapitalRx using BIN: 610852/PCN: 2001. Not valid for uninsured/cashpaying patients. The patient will pay as little as $0 in out-ofpocket drug costs. For any pharmacist questions, please call 1-833-415-4346.
COBENFY Co-pay Assistance Program Terms & Conditions
1. You are insured by commercial insurance and your prescription insurance coverage does not cover the full cost of your prescription. 2. You do not have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare, Medicaid, Medigap, CHAMPUS, TRICARE, Veterans Affairs (VA), or Department of Defense (DOD) programs; patients who move from commercial plans to state or federal healthcare programs will no longer be eligible. 3. You are 18 years of age or older; and 4. You are a resident of the United States, Puerto Rico, or other U.S. Territory.
TERMS OF USE:
1. Eligible patients with an activated co-pay card and a valid prescription may pay as little as $0 per 30-day supply; monthly, annual, and/or per-claim maximum program benefits may apply and vary from patient to patient, depending on the terms of a patient’s prescription drug plan and to ensure that the funds are used for the benefit of the patient, based on factors determined solely by Bristol-Myers Squibb. 2. Offer not applicable to co-pays of $0 or less. 3. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance, health savings or flexible spending accounts, or any third party, for any part of the benefit received by the patient through this offer. 4. Acceptance of this offer confirms that this offer is consistent with the patient’s insurance and that the patient will report the value received, as may be required by insurance. 5. Card must be activated before use. Patients will be evaluated for ongoing eligibility to continue enrollment in the program. In the event patients experience a change in insurance coverage or Bristol-Myers Squibb (BMS) makes changes to the copay assistance program, patients may be required to re-enroll into the program and provide updated insurance information to determine eligibility. 6. Cash-paying patients are not eligible for co-pay assistance. 7. All program payments are for the benefit of the patient only. 8. Only valid in the United States, Puerto Rico, and other U.S. Territories; this offer is void where restricted or prohibited by law. 9. This offer is non-transferable, no substitutions are permissible, and is limited to one (1) per patient. This offer cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. 10. The Co-pay Card may not be sold, purchased, traded, or counterfeited. Reproductions of this Co-pay Card are void. 11. Bristol-Myers Squibb reserves the right to rescind, revoke, or amend this offer at any time without notice. 12. This offer is not conditioned on any past, present, or future purchase, including refills. 13. No membership fees. 14. The Co-pay Card for COBENFY is not health insurance.