Patient is responsible for applicable taxes, if any. This offer is valid for up to 12 uses, and each 30-day supply counts as 1 use. If you pay cash for your prescription, or are insured and your insurance does not cover or has a managed care restriction (step-edit, prior authorization, or NDC block), and are not a government beneficiary or Medicare eligible, you will receive up to $100 in savings on your out-of- pocket costs for each 30-day supply. Maximum savings from offer will not exceed $500 per month between Januand Maand $200 per month at all other times for patient’s out-of-pocket cost (the amount paid after insurance deductions, if any). TERMS OF USEĮligible commercially insured/covered patients with no restrictions (step edit, prior authorization, or NDC block) and with a valid prescription for TRELEGY (fluticasone furoate, umeclidinium, and vilanterol inhalation powder) who present this savings card at participating pharmacies will pay as little as $0 for each covered 30-, 60-, or 90- day supply (1-3 inhalers) of TRELEGY. Void where prohibited by law, taxed, or restricted. This offer is not health insurance and is restricted to residents of the United States, Puerto Rico, and US territories. Patients enrolled in private indemnity or HMO insurance plans that reimburse them for the entire cost of their prescription drugs are also not eligible. Those on Medicare Part D, even if in the coverage gap, are not eligible. Patients enrolled in a state or federally funded prescription insurance program may not use this program even if they elect to be processed as an uninsured (cash-paying) patient. Patients are also ineligible for this program if they are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government subsidized prescription drug benefit program for retirees. This may also include state pharmaceutical assistance programs and other federal or state plans not listed. This includes patients enrolled in Medicare Part B, Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD) programs or TRICARE. Patients are not eligible for this program if they are covered by any federal or state prescription insurance program. Patients may be eligible for this offer if they have commercial insurance and insurance does not cover the full cost of the prescription, or if they are not insured and are responsible for the cost of their prescriptions. Who is eligible to receive the Savings Program Offer for TRELEGY? ELIGIBILITY Eligibility Requirements and Restrictions
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