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Print out this savings card. 2. Fill your prescription at the pharmacyand bring your savings card. 3. See Terms and Conditions below for additional information. Pharmacist is required to provide a copy of and review the accompanying GRANIX Patient Savings Program Terms and Conditions with the patient prior to redeeming this offer. GRANIX (tbo-filgrastim) Injection Patient Savings Program. Terms and Conditions: » Subject to program limitations and terms and conditionsthe GRANIX Patient Savings program is available to patients who have a valid GRANIX prescription and who have commercial insurance coverage for GRANIX. No substitutions permitted. Patients with commercial insurance coverage that does not provide formulary coverage for GRANIX are NOT eligible for the Patient Savings program. The Patient Savings program does not cover GRANIX dispensed or administered under commercial insurance as adjudicated under a medical plan. » Patients enrolled in any state or federally funded healthcare programincluding but not limited toMedicareMedigapMedicaidVADODTRICAREPuerto Rico Government Health Insurance Planand Medicare-eligible patients enrolled in an employer-sponsored health plan or prescription drug benefit program for retireesare NOT eligible for the Patient Savings program. » Uninsured and cash-paying patients are NOT eligible for the Patient Savings program. » Eligible Patients may pay as little as $0 on each fill. Annual benefit limits per individual apply and out of pocket expenses may vary. Patients are responsible for all amounts that exceed these Patient Savings program benefit limits. If the prior authorization is approved by the commercial insurerthen the patient remains eligible for the Patient Savings program. If the prior authorization is denied by the commercial insurerthen the patient is no longer eligible for the Patient Savings program and may not receive any additional Patient Savings program benefits. If your insurance coverage changes or if you have any questions regarding your eligibility or benefitsplease call 1-844-218-0443. » Teva has the right to reduce or eliminate patient benefit amountsbased on factors determined solely by Tevaincluding depending on the terms of a patient’s prescription drug plan and to ensure all program funds are used for the benefit of the patient. » Data related to a patient’s receipt of Patient Savings program benefits may be collectedanalyzedand shared with CephalonInc.a wholly-owned subsidiary of Teva Pharmaceutical Industries Ltd. and its affiliates (“Tevaâ€�)for market research and other purposes (including with the patient’s treating physician towards helping to verify or coordinate insurance coverage or otherwise obtain payment for the patient’s treatment with GRANIX) related to assessing the Patient Savings program. Data shared with Teva will be aggregated and de-identifiedmeaning it will not identify patients. » The Patient Savings program is restricted to residents of the United States and United States territories. Patients residing in or receiving treatment in certain states may not be eligible. » The Patient Savings program is intended for the benefit of patientsnot their insurance plans or other third parties. Patients whose commercial insurance plans do not apply Patient Savings program payments to satisfy patient out-of-pocket cost sharing amounts may not be eligible for the Patient Savings program. Similarlypatients whose commercial insurance plans require use of the Patient Savings program as a condition of the plan waiving some or all of otherwise applicable patient out-of-pocket cost sharing amounts may not be eligible for the Patient Savings program or have a reduced annual maximum program benefit. If you believe your commercial insurance plan may have such limitationsplease call 1-844-218-0443. » The Patient Savings program is not health insurance. Patients may not seek reimbursement for the value received from the Patient Savings program from any third-party payersincluding a flexible spending account or healthcare savings account. Participating in this program means that you are ensuring you comply with any required disclosure regarding your participation in the Patient Savings program of your insurance carrier or pharmacy benefit manager. » The Patient Savings program is void if copiedtransferredpurchasedaltered or tradedand where prohibited and restricted by law. The Patient Savings program is not available to residents of Massachusetts. The Patient Savings program is not transferable. No substitutions are permitted. The Patient Savings program may not be soldpurchasedtradedor counterfeited. Void if reproduced. The Patient Savings program benefit cannot be combined with any other financial assistance programfree trialdiscountprescription savings cardor other offer. Teva reserves the right to make eligibility determinationsto set Program benefit maximumsto monitor participationand to changerescindrevokeor discontinue this Patient Savings program at any time without notice. If you have any questions regarding this Patient Savings programyour eligibility or benefits or if you wish to discontinue your participationcall 1-844-218-0443. » These Terms and Conditions are valid for GRANIX dispensed between 10/1/2022 and 12/31/2023. Expiration Date: 12/31/2023. To the Pharmacist: » By redeeming this Patient Savings programyou are certifying that you understand and agree to comply with the Terms and Conditions above. » When you apply this offeryou are certifying that you have not submitted and will not submit a claim for reimbursement under any federalstateor other governmental program for this prescription. » Submit claim to CHANGE HEALTHCARE. If primary coverage existsinput offer information as secondary coverage and transmit using the COB segment of the NCPDP transaction. For questionsplease call the Change Healthcare Help Desk at 1-800-433-4893. To the Patient: » By redeeming this Patient Savings programyou are certifying that you understand and agree to comply with the Terms and Conditions above. Financial assistance for Granix Commercially insured and cash-paying patients may be eligible for GRANIX financial assistance Up to $10,000 savings per calendar year. BIN 004682 PCN CN Group EC74008003 Member ID 69468968630 EXPIRES: 12/31/2023 $0 Out of Pocket © 2022 CephalonInc.a wholly-owned subsidiary of Teva PharmaceuticalsInc. USA. GRX-41457 December 2022 Please see GRANIX Full Prescribing Information. Please see GRANIX Full Prescribing Information. S:8.5" S:11" T:8.5" T:11" B:8.5" B:11" S:8.5" S:11" T:8.5" T:11" B:8.5" B:11" 0 2072838310 2072838310 TT Slug OTF TTSlugOTF OpenType - PS -- 0 002.000 0 4012112768 4012112768 Teva Sans TevaSans-Regular OpenType - PS -- 0 1.001 0 213276564 213276564 Teva Sans TevaSans-Bold OpenType - PS -- 0 1.001 endstream endobj 7 0 obj <> endobj xref 0 8 0000000000 65535 f 0000038443 00000 n 0000038955 00000 n 0000039001 00000 n 0000039043 00000 n 0000039396 00000 n 0000039448 00000 n 0000052400 00000 n trailer <<8A5D65579A9849F491E1EC15AEA0B1FD>]>> startxref 116 %%EOF