Get your EMSAM®
Instant Savings Card.
You pay only the first $20 of your co-pay for each of your prescriptions (up to 12 prescriptions). Mylan Specialty L.P. will pay up to $500 per month of your remaining co-pay. That's a maximum savings of up to $6,000 annually!
If you are eligible for the EMSAM Savings Card program, you can reuse your card for each prescription (up to 12 prescriptions) through December 31, 2017.
Fill out the following form. Certain restrictions apply. See below for Terms and Conditions. If you qualify, you are just a few minutes away from downloading your card.
This SAVINGS card can be used to reduce the amount of your out-of-pocket expense for EMSAM® Transdermal System up to a maximum of $500 per month after your pay the first $20 for a 30-day supply. No other purchase is necessary. This offer can be used an unlimited number of times through December 31, 2017. Valid prescription with Prescriber ID# required.Eligibility Requirements: This SAVINGS card can be redeemed only by patients or patient guardians who are 18 years of age or older who are a resident of the United States and its territories. Patients must have commercial insurance. Not valid for uninsured patients (except for commercially insured patients without coverage for EMSAM® Transdermal System) and patients who are covered by any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TriCare (regardless of whether EMSAM® Transdermal System is covered by such government program); if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; or if the patient’s insurance plan is paying the entire cost of this prescription. Void outside the US and its territories or where prohibited by law, taxed, or restricted. This program is valid in Massachusetts through June 30, 2019, unless otherwise amended or extended by Massachusetts.
This SAVINGS card is not health insurance. The SAVINGS card is not transferable and the amount of the benefit cannot exceed the patient’s out-of-pocket expenses. Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Mylan Specialty reserves the right to amend or end this program at any time without notice. Data related to your redemption with this SAVINGS card may be collected, analyzed, and shared with Mylan Specialty for market research and other purposes related to assessing coupon programs. Data shared with Mylan Specialty will be aggregated and de-identified, meaning it will be combined with data related to other SAVINGS card redemptions and will not identify you. The SAVINGS card is not redeemable for cash.
Patient Instructions: Present your SAVINGS card and prescription drug insurance card, along with a valid prescription for the EMSAM® Transdermal System. By using this SAVINGS card, you acknowledge that you currently meet the eligibility criteria and that you understand and will comply with the following additional terms and conditions:
Pharmacist Instructions: When you use this SAVINGS card, you are certifying that you have received this SAVINGS card from an eligible patient; you have dispensed the product as indicated; you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription; and you will otherwise comply with the terms hereof. You further certify that your participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that you have as a pharmacy provider, and that you will report the use of this SAVINGS card to the patient’s insurer if required.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088
EMSAM (selegiline transdermal system) is a monoamine oxidase inhibitor (MAOI) indicated for the treatment of adults with major depressive disorder (MDD).