Activate for the SIMBRINZA® Co-Pay Card Savings Program

* Limitations apply. Valid only for those with private insurance. The Simbrinza® Co-Pay Card Program includes the Co-Pay card and Rebate. Eligible, commercially insured patients may pay as little as $30 in out of pocket expenses for Simbrinza® with a maximum benefit of $2,000 per calendar year. Patients must be 16 years or older to be eligible. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, or (iii) where the patient's insurance plan reimburses for the entire cost of the drug. The value of this program is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations and maximums, including applicable co-payments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.


Please provide the information below

 

You are enrolling as:

A patient over 18 years of age
A caregiver or patient guardian over 18 years of age

Do you already have the Simbrinza® Co-Pay card?

Yes
No

PATIENT'S FIRST NAME

PATIENT'S LAST NAME

PATIENT'S ADDRESS

PATIENT'S CITY

PATIENT'S STATE

PATIENT'S ZIP

PATIENT'S BIRTH DATE

PATIENT'S GENDER

Male
Female
Prefer Not To Say

PATIENT'S PRIMARY PHONE

PATIENT'S MOBILE PHONE (Optional)

PATIENT'S E-MAIL (Optional)




What type of prescription coverage does the patient have?

What type of prescription coverage does the patient have?

The patient has commercial (also known as private) insurance.
The patient is enrolled in a state- or federally funded program (including, but not limited to, Medicare, Medicaid, VA, DoD, or Tricare).
The patient pays cash for the full price of the prescription.