*Terms and Conditions:
*By using the Olumiant Savings Card (“Card”), you attest that you meet the eligibility criteria, agree to, and will comply with the Terms and Conditions described below:
This Card expires on 12/31/2024. Patients must first use their card by 12/31/2021 and are eligible for savings for up to 36 months of therapy, provided they continue to meet program terms and conditions. Patient must have coverage for Olumiant with their commercial drug insurance to pay as little as $5 monthly for a 30-day supply of Olumiant, subject to a monthly cap of wholesale acquisition cost plus usual and customary pharmacy charges and a separate $12,000 maximum annual cap. Patient must have commercial drug insurance, diagnosis consistent with FDA approved product labeling, insurance provider denied coverage, and a denied prior authorization (PA) for Olumiant to pay as little as $25 monthly for a 30-day supply of Olumiant, subject to a monthly cap of wholesale acquisition cost plus usual and customary pharmacy charges. Continued participation in $25 monthly program requires appeal submission and decision within 6 months post program initiation and a new PA or medical exception (ME) every 12 months, to verify coverage status and potential eligibility for the $5 monthly program. Participation in the program requires a valid patient HIPAA authorization. Patient is responsible for any applicable taxes, fees, or amounts exceeding monthly or annual caps.
Offer void where prohibited by law. This offer is invalid for patients without commercial drug insurance or those whose prescription claims are eligible to be reimbursed, in whole or in part, by any governmental program, including, without limitation, Medicaid, Medicare, Medicare Part D, Medigap, DoD, VA, TRICARE®/CHAMPUS, or any state patient or pharmaceutical assistance program. If you live in Massachusetts, the Card expires on the earlier of: (i) the expiration date of this Card (12/31/2024); (ii) the date an AB-rated generic equivalent for Olumiant becomes available; or (iii) [12/31/2020], absent a change in Massachusetts state law. If you live in California, the Card expires on the earlier of: (i) the expiration date of this Card 12/31/2024 or (ii) the date an FDA-approved therapeutically equivalent for Olumiant or over-the-counter product with the same active ingredients becomes available. Available only in the US and Puerto Rico for residents of the US and Puerto Rico. By accepting this offer, you agree that if you are required to do so under the terms of your insurance coverage for this prescription or are otherwise required to do so by law, you should notify your insurance carrier of your redemption of this Card. This offer cannot be combined with any other program, discount, discount card, cash discount card, incentive, or similar offer involving Olumiant. It is prohibited for any person to sell, purchase, or trade; or to offer to sell, purchase, or trade; or to counterfeit this Card. This offer may be terminated, rescinded, revoked, or amended by Lilly USA, LLC, at any time without notice. This Card is not health insurance. This Card expires on 12/31/2024.
