Patient Enrollment Option

Please see eligibility criteria and complete terms and conditions below.

If you would like to enroll in the Cuvposa Patient Program, please provide your information below. By enrolling in this program you may be contacted in the future with useful product information. You do not need to enroll in the Cuvposa Patient Program to be able to use your Cuvposa Savings Card.

To skip the enrollment option, please click on the following button:

Are you the primary caregiver or patient?

Primary caregiverPatient

Name:
Address:
City:	State: Zip:
Phone:
Email:

I certify that I am the primary caregiver and I am 18 years of age or older.

Merz North America believes your privacy is important. By providing your name, address, e-mail address and other information, you are giving Merz North America and companies working with Merz North America permission to market or advertise to you regarding the medical condition(s) in which you have expressed an interest, as well as other general health-related information from Merz North America. Merz North America will not sell or transfer your name, address, or e-mail address to any other party for their own marketing use.

For additional information regarding how Merz North America handles your information please see our privacy statement.

ELIGIBILITY CRITERIA

GENERAL TERMS AND CONDITIONS:

This savings program is good for prescription fills of Cuvposa Rx products. Original savings card must be presented to the pharmacist at the time each prescription is filled and is good for use only with a valid prescription for Cuvposa. Not valid if reproduced.
Offer good only in the USA.
Merz Pharmaceuticals, LLC reserves the right to rescind, revoke or amend this offer at any time without notice.
Savings card is not transferable. Void where prohibited by law, taxed or restricted.
It is a violation of federal law to buy, sell, or counterfeit this savings card.
This card is not valid for prescriptions reimbursed under Medicaid, Medicare, or any federal or state healthcare programs (including state prescription drug programs).
This savings card is not insurance, and savings on a prescription fill are not contingent on the purchase of any product.

TO THE PATIENT: To be eligible for this offer: (a) where third-party reimbursement covers a portion of your prescription, this savings card is valid only for the amount of your actual out-of-pocket expenses up to a maximum of $40.00 for each Cuvposa prescription fill, (b) your prescription MUST NOT be covered/reimbursed by a federal healthcare program, including Medicare or Medicaid, or by any similar federal or state program, including a state pharmaceutical assistance program, and (c) you MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). Acceptance of this savings card offer must be consistent with the terms of any insurance benefit. You understand and agree to comply with the terms and conditions of this offer above.

TO THE PHARMACIST: For questions regarding processing, please call 1-855-740-3040. By redeeming this savings card I certify that (i) I have received this savings card from an eligible patient, (ii) I have dispensed the product as indicated, (iii) I have not submitted, and will not submit, a claim for reimbursement to the patient or any federal, state or other governmental payer, and (iv) I will otherwise comply with the terms hereof. I further certify that my participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that I have as a pharmacy provider. I agree to retain processing records for 3 years or as required by law, whichever is longer, and to grant Merz Pharmaceuticals, the right to audit submissions.

PATIENT/PHYSICIAN QUESTIONS: For any questions regarding the $40.00 Cuvposa savings card, please call 1-855-740-3040.