SAVINGS CARD
for as little as
$0
A Month
LET’S GET YOU STARTED with
savings & Support
Take advantage of personalized support and savings with the QULIPTA Patient Savings Program.
Fill out the information below and submit to enroll.
Once enrolled, here’s what you can expect:
quick, affordable access to Qulipta
Eligible commercially insured patients pay as little as $0 a month. If you experience an insurance delay or denial, eligible patients can receive QULIPTA shipped directly to their door*
quick, affordable access to Qulipta
Eligible commercially insured patients pay as little as $0 a month. If you experience an insurance delay or denial, eligible patients can receive QULIPTA shipped directly to their door*
quick, affordable access to Qulipta
Eligible commercially insured patients pay as little as $0 a month. If you experience an insurance delay or denial, eligible patients can receive QULIPTA shipped directly to their door*
Questions? Support is only a phone call away. Call 1-855-QULIPTA (1-855-XXXXX) Monday through Friday, 8AM-8PM ET
*Terms and Conditions apply. This benefit covers QULIPTA. Eligibility: Available to patients with commercial prescription insurance coverage for QULIPTA who meet eligibility criteria. Copay assistance program is not available to patients receiving prescription reimbursement under any federal, state, or government-funded insurance programs (for example, Medicare [including Part D], Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs 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 the QULIPTA Patient Savings Program Card and patient must call QULIPTA at 1-800-QULIPTA and stop use of the copay card. Patients residing in or receiving treatment in certain states may not be eligible. Patients may not seek reimbursement for value received from QULIPTA Patient Savings Program, including the copay card, from any third-party payers. Offer subject to change or discontinuance without notice. Restrictions, including monthly maximums, may apply. This is not health insurance.