The MYOBLOC Co-pay Program assists eligible patients with cervical dystonia with their out-of-pocket expenses associated with MYOBLOC and the related administration expenses. With no limit per injection, eligible patients may receive up to $4,000 per year of assistance with permitted out-of-pocket expenses.¹

Patients who are 18 years or older, diagnosed with cervical dystonia (G24.3) or chronic sialorrhea (K11.7), a legal US resident, who have commercial insurance coverage according to the terms and conditions of the program and are NOT enrolled in a government insurance plan (eg, Medicare, Medicaid, TRICARE®, and other federal- or state-funded programs).²

No enrollment forms needed. HCP staff can enroll patients by calling 1-888-461-2255, Option 3. Patients can enroll themselves by calling 1-888-461-2255, Option 3, as well.

Once eligible for participation, the patient’s eligible out-of-pocket expenses may be paid directly to the site of care (administering office or pharmacy) on the patient’s behalf, or to the patient as a reimbursement for out-of-pocket expenses they paid to the site of care. Irrespective of who will receive the co-pay payment, the site of care must first file a claim for MYOBLOC and the related injection-administration expenses with the patient’s private insurance carrier(s). An Explanation of Benefits that shows payment for MYOBLOC and the related injection expenses is required with supporting evidence to establish out-of-pocket expenses before any such reimbursement is authorized by the MYOBLOC Co-pay Program [See Reference 1 for Michigan, Rhode Island, and Minnesota residents].

Upon approval into the program, eligible costs for the patient’s MYOBLOC injections may be submitted for payment. The program administrator will verify that the costs are eligible for payment. Payment for eligible costs will be issued to the site of care via a virtual credit card number within 2 business days of the receipt of information validating eligible out-of-pocket expenses. If the site of care requires a check reimbursement, that check will be issued and mailed within 3-4 weeks. Any pharmacy using the Co-pay Program may use the patient’s card ID, Rx and BIN to process and receive payment on claims.

1. This offer is valid for commercially insured patients only and is good for use only with a MYOBLOC prescription at the time the prescription is filled or after the product is administered to the patient. 2. Depending on insurance coverage, eligible insured patients may pay no more than zero dollars ($0) for MYOBLOC and the administrative services associated with MYOBLOC, up to a maximum savings limit of four thousand dollars ($4,000) per year. Patient out-of-pocket expense may vary. 3. This offer is not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this Program if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees. 4. The offer is valid for one (1) year. 5. Supernus reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating pharmacies or Healthcare Providers. 7. Void if prohibited by law, taxed, or restricted. 8. Residents of Michigan, Rhode Island, and Minnesota are not eligible for assistance with payment for injection or injection guidance-related costs, but may receive assistance with MYOBLOC. 9. This Program is not transferable. The selling, purchasing, trading, or counterfeiting of this Program is prohibited by law. 10. This Program is not insurance. 11. By redeeming this assistance, you represent that, to the best of your knowledge, the patient is eligible to participate in the Program and that you understand and agree to comply with the terms and conditions of this offer.
 

MYOBLOC is available at no charge to eligible patients who are approved for the Patient Assistance Program.      
 

Eligibility Criteria:

• Patients for whom MYOBLOC is prescribed by a licensed physician to treat cervical dystonia or chronic sialorrhea
• Patients who have no health insurance benefits for MYOBLOC
  • Insured—No benefits
  • Uninsured
• Patient cannot otherwise afford MYOBLOC therapy
• Patient is a legal United States resident
• Patient is injected with MYOBLOC (J-Code J0587) accompanied with ICD-10 code G24.3 for cervical dystonia or ICD-10 code K11.7 for chronic sialorrhea

For patients who are approved for the Patient Assistance Program:

• MYOBLOC is provided at no charge
• MYOBLOC is shipped directly to the healthcare provider marked for patient use
• Qualified patients are eligible to receive MYOBLOC injections for two (2) dates of services provided that they do not subsequently gain health insurance benefits
  • Patient may re-apply for additional dates of service
• Patient is responsible for any charges related to Healthcare Provider