The Ascend Laboratories Co-pay Program includes the co-pay card, or rebate with a combined limit of $40 per 30-day supply prescription. Patient is responsible for any costs over $40.

• This offer is only available to patients with private insurance. The program is not available for patients who: (i) are enrolled in Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program; (ii) are not using insurance coverage at all; (iii) are enrolled in an insurance plan that reimburses for the entire cost of the drug; or (iv) where product is not covered by patient’s insurance.
• The value of this program is exclusively for the benefit of patients and is intended to be credited toward patient out-of-pocket obligations, including applicable copayments, coinsurance, and deductibles.
• Proof of purchase may be required.
• Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account.
• Patient is responsible for complying with any applicable limitations and requirements of his/her health plan related to the use of the program.
• Program is not valid where prohibited by law. Valid only in the United States and Puerto Rico.
• This program is not health insurance. This program may not be combined with any third-party rebate, coupon, offer, or cash discount card.
• Novartis reserves the right to rescind, revoke, or amend the program and discontinue support at any time without notice.

Patient Instructions: Present this card and your insurance card along with a valid prescription at any participating pharmacy or through mail order. This co-pay card will cover up to $40 of your out of pocket costs. If patient reaches the maximum per 30-day prescription of $40, patient will be responsible for the difference.

When you use this card, you are certifying that you understand and agree to comply with the program Terms and Conditions above.