ELIGIBILITY: You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription, or you are not insured and are responsible for the cost of your prescriptions. Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees. If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient. This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 18 years of age.
TERMS OF USE: Eligible commercially insured patients with a valid prescription for LOKELMA® (sodium zirconium cyclosilicate) who present this savings card at participating pharmacies will pay as low as $0 for up to a 30-packet supply, subject to a maximum savings of $350 per 30-packet supply; patient out-of-pocket expenses may vary. If you pay cash for your prescription, AstraZeneca will pay up to the first $250, and you will be responsible for any remaining balance, for each monthly prescription. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursem*nt from health insurance or any third party for any part of the benefit received by the patient through this offer. AstraZeneca reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription at the time of purchase. Maximum savings limit applies. For additional details about this offer, please visit www.lokelmasavings.com. If you have any questions regarding this offer, please call 1-844-565-3562.
BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.
Pharmacist Instructions for a Patient With an Eligible Third Party:
For Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. This will reduce the eligible patient’s out-of-pocket costs to as low as $0 for up to a 30-packet supply, subject to a maximum savings limit of $350 per 30-packet supply; patient out-of-pocket expenses may vary. Reimbursem*nt will be received from Change Healthcare.
Pharmacist Instructions for Insured/Not Covered Patients: Submit the claim to the primary Third-Party Payer first; if the primary claim submission shows a managed care restriction (step-edit, prior authorization or NDC block), continue the claim adjudication process and submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 3. This will reduce eligible patient’s out-of-pocket costs to as low as $0 for up to 30-packet supply, subject to a maximum savings limit of $350 per 30-packet supply; patient out-of-pocket expenses may vary. Reimbursem*nt will be received from Change Healthcare.
Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (eg, 1) is required. The card will cover up to a maximum of $250 for up to a 30-packet supply. Reimbursem*nt will be received from Change Healthcare. Valid Other Coverage Code Required. For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-433-4893.
Program managed by ConnectiveRx, on behalf of AstraZeneca.
