Eligibility for LYBALVI® Co-pay Savings Program (Program): This Program is only available to commercially insured patients who are 18 years or older with a valid LYBALVI prescription. Health plan requirements for a prior authorization and/or step therapies must be attempted, and an outcome documented, regardless of the outcome, prior to using this co-pay offer. This Program is not available to patients who are enrolled in, or covered by, any local, state, federal or other government program that pays for any portion of medication costs, including but not limited to Medicare, including Medicare Part D or Medicare Advantage plans; Medicaid, including Medicaid Managed Care and Alternative Benefit Plans under the Affordable Care Act; Medigap; VA; DOD; TRICARE; or a residential correctional program. Patients who become eligible for any government program that pays for any portion of medication costs will no longer be eligible for this Program. Program is not valid for cash paying patients. Patients must live in the United States or Puerto Rico. Patients must meet the Program requirements every time they fill their prescription to receive the benefit.
Program Benefit: Maximum savings limit applies; patients' out-of-pocket expenses may vary. Eligible patients using the LYBALVI Co-pay Savings Card may pay as little as $0 per 30-day supply for the first 3 prescriptions in the Program. Beginning at the fourth prescription and thereafter, eligible patients may pay as little as $20 with a maximum co-pay savings of $450 per 30-day supply. Eligible patients receiving benefits from the LYBALVI Automatic Co-pay Savings Program may use the LYBALVI Co-pay Savings Card in combination with the Automatic Co-pay Savings Program which may result in additional savings where applicable. Click here to learn more about Automatic Co-pay Savings eligibility and benefits.
Co-pay savings card benefits may be received for valid co-pay savings card claims only that are submitted with a date of service that is up to 90 days prior to the initial enrollment date. The LYBALVI Co-pay Savings Card expires after 5 years but may be renewed if all eligibility criteria are met.
Additional Terms of Use: All Program payments are for the benefit of the patient only. This Program offer is not conditioned on any past, present, or future purchase, including refills. To use this Program, participating patients are responsible for following any health plan requirements, including any requirements to inform the health plan how much co-payment support they get from this Program. Program may be subject to plan benefit design requirements. Alkermes may rescind, revoke, or amend this Program, eligibility, benefits, and requirements at any time without notice, including in specific states. This Program offer is limited to one per patient and may not be used with any other coupon, discount, prescription savings card, free trial, or other offer (except that the LYBALVI Co-pay Savings Card may be used in combination with the Automatic Co-pay Savings Program where applicable). The Program benefit is not transferable; and may not be sold, purchased, or traded, or offered for sale, purchase, or trade. Void where prohibited by law, taxed or otherwise restricted. The Program is not insurance.
Use and Disclosure of Information: Patients enrolling in the Program may be asked to provide personal information, including information related to their health insurance and treatment. This information is needed for the Program Administrator to enroll patients in the Program. Program Administrator will not share the patient’s personal information with anyone except where legally permitted. Data shared with Alkermes by the Program Administrator will be aggregated and de-identified and may be used by Alkermes for its own internal business purposes and/or to improve or modify the Program. For more information, see Alkermes’ Privacy Policy at www.alkermes.com/privacy.
To the Patient: Present the LYBALVI Co-pay Savings Card and prescription for LYBALVI to the pharmacist to participate in this program. When using this card, you certify that you understand and agree to all of the Program Terms and Conditions and that you meet, or are the legal guardian of a patient who meets, the Program requirements. For questions about your eligibility or benefits, if your insurance has changed, or if you wish to discontinue your participation, call the LYBALVI Co-pay Savings Program at 1-855-820-9624 (8:00 AM-8:00 PM ET, Monday-Friday).
To the Pharmacist: When using the LYBALVI Co-pay Savings Card, you certify that you will comply with the above Terms and Conditions and that you have not submitted and will not submit a claim for reimbursement under any local, state, federal, or other government program for this prescription. Submit transaction to McKesson Corporation (“Program Administrator”) using BIN 610524. Submit commercial insurance as primary coverage, input co-pay savings card information as secondary coverage, and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response. Acceptance of this card and your submission of claims for LYBALVI are subject to the LoyaltyScript® Program terms and conditions posted at www.mckesson.com/mprstnc. Claims submitted utilizing the Program are subject to audit or validation. For questions regarding setup, claim transmission, patient eligibility, or other issues, call the LoyaltyScript® Program for the LYBALVI Co-pay Savings Program at 1-855-820-9624 (8:00 AM-8:00 PM ET, Monday-Friday).
