SANCUSO Copay Assistance Card Program


  1. Show the Copay Assistance Card and your valid prescription each time you pay for your prescription.
  2. Pay the initial $20 of your copay for each prescription of Sancuso and any remaining out-of-pocket cost will be reduced by $300 for 1 patch to a maximum of $1200 per month for 4 or more patches.*
  3. Save your Copay Assistance Card – this card can be used multiple times up to 48 patches per patient. In no case, will the monthly benefit exceed $300 for 1 patch, $600 for 2 patches, $900 for 3 patches or $1200 for 4 or more patches.
Examples of what you might pay:
Number of
Patches
Out-of-Pocket
Cost
Copay Card
Pays
= You Pay
1 $250   $230   $20
2 $500   $480   $20
3 $900   $880   $20
4 $1,300   $1,200   $100
*Offer expires 01/31/2019. For qualifying patients only. Restrictions apply.
Program rules and eligibility provided on copay card. This coupon is not insurance.

FARESTON Copay Assistance Card Program


  1. Show the Copay Assistance Card and your valid prescription each time you pay for your prescription.
  2. Pay the initial $20 of your copay. Any remaining out-of-pocket costs will be reduced by up to $150 per month.
  3. Save your Copay Assistance Card—this card can be used once a
    month for up to 12 prescriptions. In no case will the monthly benefit
    exceed $150.
What you pay:
Out-of-Pocket Cost - Copay Card Pays = You Pay
$75   $55   $20
$170   $150   $20
$250   $150   $100
Please see important safety information listed on the back of the card, including boxed warning. Offer expires 01/31/2019. This offer is not valid for Medicare, Medicaid, VA or DOD patients. Please see back of the card for more program details.
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