DETERMINE ELIGIBILITY FOR THE $0 CO-PAY* CARD

To find out if you are eligible for a myfortic® (mycophenolic acid delayed-release tablet), Neoral® (cyclosporine capsules, USP) MODIFIED, or SANDIMMUNE® (cyclosporine capsules, USP) $0 Co-Pay Card, simply answer the questions below. Please note that this information must be entered by you or a caregiver, and cannot be entered by a third party.

*Limitations apply. See program terms and conditions below. This offer is not valid under Medicare, Medicaid, or any other federal or state program. Novartis reserves the right to rescind, revoke, or amend this program without notice.

Eligibility

Personal Info

Done

1.

I certify that I am over the age of 18 and that I am the patient or that I am the patient's caregiver and have the patient's consent to proceed with the enrollment of this savings card.

YES

NO

Patient Ineligible You must be 18 years or older to complete this enrollment form. Please have a parent or caregiver who is at least 18 years of age complete the enrollment process or call 1-877-952-1000.

Patient Ineligible

You must be 18 years or older to complete this enrollment form. Please have a parent or caregiver who is at least 18 years of age complete the enrollment process or call 1-877-952-1000.

2.

Do you have commercial (also known as private) insurance?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as it's only valid for those with commercial insurance. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as it's only valid for those with commercial insurance. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

3.

Are you enrolled in any state or federally funded programs, including but not limited to Medicare, Medicaid, VA, DoD, or Tricare?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as the offer is not valid under Medicare, Medicaid, or any other federal or state program. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as the offer is not valid under Medicare, Medicaid, or any other federal or state program. Please call 1-877-952-1000 to find out if there are other forms of support for you. Learn more.

4.

Are you paying cash for the full price of the prescription?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as the offer is not valid for cash-paying patients. Please call 1-877-952-1000.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as the offer is not valid for cash-paying patients. Please call 1-877-952-1000.

5.

Are you a resident of Massachusetts?

YES

NO

Patient Ineligible It doesn't appear that you are eligible for this savings card, as the offer is not valid for residents of Massachusetts. Please call 1-877-952-1000.

Patient Ineligible

It doesn't appear that you are eligible for this savings card, as the offer is not valid for residents of Massachusetts. Please call 1-877-952-1000.

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Terms and conditions

*Limitations apply. Valid only for those with commercial insurance. Offer not valid under Medicare, Medicaid, or any other federal or state program, for cash-paying patients, where product is not covered by patient's commercial insurance, or where plan reimburses you for entire cost of your prescription drug. Offer is not valid where prohibited by law. Offer is not valid for residents of Massachusetts. Valid only in the US and Puerto Rico. This program is not health insurance. Offer may not be combined with any other rebate, coupon, or offer. This card is the property of Novartis Pharmaceuticals Corporation and must be returned upon request. Novartis reserves the right to rescind, revoke, or amend the program without notice. Patient certifies responsibility for complying with applicable limitations, if any, of any commercial insurance and reporting receipt of program rewards, if necessary, to any commercial insurer. This offer expires on 12/31/17.

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