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Savings Card Eligibility
I agree to the full Terms and Conditions and Eligibility of the Simtriyo GO Savings Program.
Program Consent
| I agree that Otsuka America Pharmaceutical, Inc. (“Otsuka”) and its contracted third parties may send me information regarding this Savings Card, including but not limited to prescription status, remaining benefit, refill reminders, via the phone number provided. I understand that I am responsible for securing any of my own devices or accounts from unauthorized access. Consent to receiving SMS messages is not a condition of purchase of goods or services. I understand that form time to time the Otsuka Privacy Policy may change, and that I should check www.otsuka-us.com/privacy-policy for the most recent version of the Privacy Policy. I have the ability to text STOP to opt out of receiving Simtriyo GO Savings Program messages. |
Marketing Communications Consent
By opting in, I confirm that I am 18 years of age or older and I understand that the information I have provided will be used by Otsuka America Pharmaceutical, Inc. (“Otsuka”) and its contracted third parties to contact me by email, text message, and/or direct mail with relevant information about ADHD, Otsuka products, and/or participation in market research opportunities that may be relevant to me. I will have the ability to opt out from receiving Otsuka communications at any time by calling 1-855-627-7873 or by following the opt-out instruction within the communications. By submitting this form, you are agreeing to our Terms of Use and Privacy Policy.
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Terms and Conditions: This Savings Card Program is offered by Otsuka America Pharmaceutical, Inc. and applies to a valid SIMTRIYO® (centanafadine) prescription. Eligible patients with commercial insurance that have coverage for SIMTRIYO may pay as little as $20. Eligible patients with commercial insurance that do not have coverage for SIMTRIYO may pay as little as $20 for up to four (4), 30-day supplies per lifetime. Patients who do not have coverage after four (4) fills may continue paying as little as $115 per 30-day supply. Offer is subject to a maximum benefit of wholesale acquisition cost plus usual and customary pharmacy charges.
Limit 1 card per patient. This Savings Card Program is non-transferable, no substitutions are permissible, and this offer is intended solely for the patient’s benefit. Maximum benefits and copay assistance redemption methods may vary as necessary to ensure compliance with these Terms and Conditions. Up to 13 uses per calendar year.
Eligibility: Patients must have commercial drug insurance and a prescription consistent with FDA-approved product labeling. Patients are not eligible for this program if their prescription is covered in whole or in part by any state or federal healthcare program, including, but not limited to, Medicare Part D, Medicaid (including Medicaid managed care), Medigap, Veterans Affairs (VA), or Department of Defense (DOD) or TRICARE programs, or where prohibited by law or by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any such federal, state, or government-funded healthcare program, patient will no longer be able to use this Savings Card Program. Only valid in U.S. and Puerto Rico; provided, however, that if generic alternative is or becomes available, residents of Massachusetts and California shall not be eligible to participate in this Savings Card Program. The Savings Card Program is void where prohibited by law, taxed, or restricted. Other conditions may apply. Patients may not seek reimbursement for value received from this Savings Card Program from any third-party payers. Otsuka America Pharmaceutical, Inc. has the right to rescind, revoke, or amend this program at any time without notice. This assistance offer is not health insurance.