ELIGIBILITY
REGISTER
COMPLETE
You must be 18 years or older to complete this enrollment form. Please have a parent or caregiver who is at least 18 years of age complete the enrollment process or call 1-866-877-4633.1-866-877-4633.
Patient Ineligible: It doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as it's only valid for those with private (nongovernmental) insurance. If you are unsure about your type of insurance, please contact your insurer or call 1-800-245-5356.1-800-245-5356. to find out if there are other forms of support for you. Learn more .
Patient Ineligible: It doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as the offer is not valid for Massachusetts or California residents. Please call 1-800-245-5356.1-800-245-5356. to find out if there are other forms of support for you. Learn more .
Are you enrolled in a federal or state health care program or plan that helps cover the cost of your prescription medication? This includes, but is not limited to, Medicare Part D, Medicare Advantage, Medicaid, VA, DoD, TRICARE, and any other government-sponsored pharmaceutical benefit program.
Patient Ineligible: It doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as the offer is not valid under Medicare, Medicaid, or any other federal or state program. If you are unsure about your type of insurance, please contact your insurer or call 1-800-245-5356.1-800-245-5356. to find out if there are other forms of support for you. Learn more .
Patient Ineligible: It doesn't appear that you are eligible for the FOCALIN XR Co-Pay Card, as the offer is not valid for cash-paying patients. Please call 1-800-245-5356.1-800-245-5356. to find out if there are other forms of support for you. Learn more .
*Terms and conditions
Limitations apply. Valid only for those with private insurance. The Program includes the Co-Pay Card, Payment Card (if applicable), and Rebate, with a combined annual limit up to $720. Patient pays the first $10 of co-pay. Novartis pays up to the next $60 per 30-day supply. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program (ii) where patient is not using insurance coverage at all, (iii), where the patient's insurance plan reimburses for the entire cost of the drug, or (iv) where product is not covered by patient's insurance. The value of this Program is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations and maximums, including applicable co-payments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this Program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. Offer not valid in CA or MA. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Novartis reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.
