EVEKEO ODT Copay Savings Program

Please provide the following information to request a savings card

To activate the card on behalf of a minor, you must be the parent, legal guardian, or representative and be at least 18 years of age*

I Agree I Disagree

Patient First Name*

Patient Last Name*

Mailing Address 1*

Mailing Address 2

City*

State/Territory*

Zip*

Phone Number*

Email Address*

Date of Birth*

You understand that the transactions processed using the savings card will be shared with Arbor Pharmaceuticals, the sponsor of the savings card. The information disclosed will include the date a transaction was processed using the savings card, the product dispensed by my pharmacist, and the amount that I will be reimbursed by Arbor Pharmaceuticals under the Evekeo® Copay Savings Program. This information will be available to Arbor Pharmaceuticals and third parties working on behalf of Arbor Pharmaceuticals, and will not be shared with anyone else.*

Yes No

You understand that the personal information you provide and information pertaining to the use of your savings card at the pharmacy will be shared with Arbor Pharmaceuticals and its third-party partners. You also authorize Arbor Pharmaceuticals and its partners to communicate with you about this program. You agree to be contacted by mail, email, and at the phone number you provided to leave voice messages. You may opt out of communications of the program entirely at any time by calling 855-558-1630.*

Yes No

Are you enrolled in any government, state or federally funded prescription benefit program? This includes Medicare, Medicaid, Medigap, VA, DOD and Tricare?*

Yes No

Your card is not valid for prescriptions purchased under Medicaid, Medicare or any other state or federal employee-benefit programs. Should you being receiving prescription benefits from such federal, state, or government funded program at any time, you will no longer be eligible to participate in this program. We may contact you by phone or mail periodically in order to verify that your eligibility for the program has not changed. Do you acknowledge your agreement with this statement?*

Yes No

You understand and agree that you have not or will not submit a claim for reimbursement under any federal, state, or other government program for the covered drug.*

I Agree I Disagree

You understand and agree that you will not sell, purchase, trade, or counterfeit the savings card.*

I Agree I Disagree

*asterisked fields are required.

IMPORTANT SAFETY INFORMATION

PRESCRIBING INFORMATION

Welcome to the EVEKEO ODT™ Copay Savings Program*

To begin activation, please enter your savings card ID

Please Provide the Following Information to Activate a Card

Please provide the following information to request a savings card

Please provide the following information to replace a savings card