With this savings offer, you could be eligible for up to $300 savings per EpiPen 2-Pak® carton. This offer can be used for a total of six (6) EpiPen 2-Pak® cartons now through December 31, 2017. Print your My EpiPen Savings Card® and bring it to the pharmacy, and keep bringing it every time you refill your prescription. Read the Terms and Conditions, and fill out the form to see if you are eligible. Certain eligibility restrictions apply. Not valid for patients enrolled in federal or state healthcare programs, such as Medicare, Medicaid, and TriCare, and not valid for uninsured patients (except for commercially insured patients without coverage for EpiPen® Auto-Injector). For full terms and conditions, visit http://www.epipen.com/copay
Mylan has recently enhanced its patient assistance program to help increase access to EpiPen®. To enroll, patients must complete the patient assistance program form with their physician. Patients can obtain additional information on the program by emailing firstname.lastname@example.org or calling Mylan Customer Relations at 1-800-395-3376 to speak with a representative.
To participate in the program, patients must meet the eligibility criteria set forth below:
- The patient must be a U.S. citizen or a legal resident living in the United States.
- The patient's gross yearly household income must fall below 400% of the current Federal Poverty Guidelines, based upon family size. Verification documents will be required.
- The patient must meet one of the following:
a. The patient must not have prescription insurance coverage through Medicaid, Medicare Part D, TriCare, a qualified health plan purchased on a state-based, partnership, or federally-facilitated Exchange, or any other public or private program orinsurer. Verification documents will be required.
Approved Documents: Denial Letter, Termination Statement, Statement from Physician, Nurse, or Patient Advocate, or Certified Notarized Statement from the Applicant
b. The patient has commercial prescription drug coverage only for generic products and the patient must not have prescription insurance coverage through any state or federally funded program including, without limitation, to Medicare, Medicaid, TriCare, or Medicare Part D. Verification documents will be required.
Approved Documents: Denial Letter, Termination Statement, Statement from Physician or Nurse, or Verification of Applicant's Coverage from the Insurer.
Approved Documents: 1040, 1040ez, W2, 4506-T, SSI Statement, Disability Statement, or Statement from Physician, Nurse, or Patient Advocate, or Certified Notarized