Icatibant Co-Pay Card 2020-04-16T21:24:32+00:00

Your out-of-pocket costs may be

$0*

Your out-of-pocket costs may be

$0*

For Leucadia’s generic version of

Firazyr® (icatibant injection)

DOWNLOAD SAVINGS CARD

By downloading this card, I affirm that I am eligible for this offer in accordance with the Terms of Use.

Download and print the PDF, then present it to your pharmacist when you fill your existing prescription.

Please see full Terms of Use and Eligibility below.

ELIGIBILITY: *You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription. Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD) programs or TriCare, and patients who are Medicare-eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees. If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient. This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 18 years of age.

TERMS OF USE: Eligible commercially insured patients with a valid prescription for Leucadia’s Icatibant Injection who present this savings card at participating pharmacies may pay as low as $0 per 30-day supply subject to a maximum savings limit for the program, patient out-of-pocket expenses may vary. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. Leucadia reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription at the time of purchase. For additional details about this offer, please visit www.leucadiapharma.com.

If you have any questions regarding this offer, please call 1-877-274-5799.

BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

PHARMACIST INSTRUCTIONS FOR A PATIENT WITH AN ELIGIBLE THIRD PARTY

For Insured/Covered Patients:
Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. This will reduce the eligible patient’s out-of-pocket costs to as low as $0 per 30-day supply subject to a maximum savings limit for the program, patient out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.

For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-433-4893.

Firazyr® is a registered trademark of Shire Orphan Therapies, GmbH.

For Leucadia’s generic version of

Firazyr® (icatibant injection)

DOWNLOAD SAVINGS CARD

By downloading this card, I affirm that I am eligible for this offer in accordance with the Terms of Use.

Download and print the PDF, then present it to your pharmacist when you fill your existing prescription.

Please see full Terms of Use and Eligibility below.

ELIGIBILITY: *You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription. Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD) programs or TriCare, and patients who are Medicare-eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees. If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient. This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 18 years of age.

TERMS OF USE: Eligible commercially insured patients with a valid prescription for Leucadia’s Icatibant Injection who present this savings card at participating pharmacies may pay as low as $0 per 30-day supply subject to a maximum savings limit for the program, patient out-of-pocket expenses may vary. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer. Leucadia reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription at the time of purchase. For additional details about this offer, please visit www.leucadiapharma.com.

If you have any questions regarding this offer, please call 1-877-274-5799.

BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

PHARMACIST INSTRUCTIONS FOR A PATIENT WITH AN ELIGIBLE THIRD PARTY

For Insured/Covered Patients:
Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. This will reduce the eligible patient’s out-of-pocket costs to as low as $0 per 30-day supply subject to a maximum savings limit for the program, patient out-of-pocket expenses may vary. Reimbursement will be received from Change Healthcare.

For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-433-4893.

Firazyr® is a registered trademark of Shire Orphan Therapies, GmbH.