Depending on your insurance coverage, eligible patients may pay $0 for their ACCRUFeR prescriptions. Check with your pharmacist for your co-pay discount. Maximum savings limits apply; patient out-of-pocket expense will vary. Offer not valid for patients enrolled in Medicare, Medicaid, other federal or state healthcare programs, or where prohibited by law. See program Terms, Conditions, and Eligibility Criteria.

TELL US ABOUT YOURSELF

FIRST NAME*

Please enter First Name.

LAST NAME*

Please enter Last Name.

MOBILE NUMBER*

Please enter Mobile Number.

EMAIL ADDRESS

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ZIP CODE*

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PLEASE HELP US DETERMINE YOUR ELIGIBILITY

Are you 18 years of age or older?

Yes

Please select Yes or No.

Are you enrolled in a state or federally funded insurance coverage, including but not limited to Medicare, Medicaid, Medigap, TRICARE, VA, DoD, or the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”)?

Yes

Please select Yes or No.

Do you have insurance coverage through a private or commercial insurance plan?

Yes

Please select Yes or No.

By activating your ACCRUFeR Savings Offer, you certify that you are not enrolled in a federal government- or state government-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these types of programs at any time, you will no longer participate in this savings program.

I have read and accept the program Terms, Conditions, and Eligibility Criteria.

Please agree to this statement to participate in this program.

IF YOU HAVE ANY QUESTIONS ABOUT THE ACCRUFeR SAVINGS PROGRAM, PLEASE CALL 1-833-757-4361.

WELCOME TO THE ACCRUFeR
PATIENT SAVINGS PROGRAM

ELIGIBLE PATIENTS MAY RECEIVE ACCRUFeR FOR $0

TELL US ABOUT YOURSELF

PLEASE HELP US DETERMINE YOUR ELIGIBILITY

WELCOME TO THE ACCRUFeR PATIENT SAVINGS PROGRAM

ELIGIBLE PATIENTS MAY RECEIVE ACCRUFeR FOR $0

TELL US ABOUT YOURSELF

PLEASE HELP US DETERMINE YOUR ELIGIBILITY

WELCOME TO THE ACCRUFeR
PATIENT SAVINGS PROGRAM