The KYNMOBI®(apomorphine HCl) Savings Program offers 2 ways to help patients save on medication costs*
Not actual card.
Individual copay amounts may vary. A maximum benefit limit also applies. Eligibility requirements and restrictions apply.
See KYNMOBI Savings Program Terms and Conditions.
Eligible commercially insured patients may pay as little as $15 per 30-count carton with the KYNMOBI Copay Savings Card
Eligible uninsured, cash-paying patients may pay as little as $195 per 30-count carton with the KYNMOBI Copay Savings Card
There are 2 ways to obtain a KYNMOBI Copay Savings Card for your patient:
By calling your Therapeutic Specialist to have one delivered to your office
No annual cap. Up to 5 cartons per month, if patients meet eligibility requirements
KYNMOBI® (apomorphine HCl) Copay Savings Card Terms and Conditions
By using this card, you acknowledge that you currently meet the following eligibility requirements:
You are 18 years of age or older.
You have a valid prescription for KYNMOBI.
You are not enrolled in any state or federal healthcare program, including, but not limited to, Medicare (including Medicare Advantage), Medicaid (including managed Medicaid plans), Medigap, VA, DOD, or TRICARE. In addition, you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.
Additional Terms and Conditions Include:
The offer applies only to prescriptions filled before the program expires or terminates.
The copay prescription shall not be submitted for reimbursement to any federal or state healthcare program, including Medicare (including Medicare Advantage), Medicaid (including managed Medicaid plans), Medigap, VA, DOD, TRICARE, or an employer-sponsored health plan or prescription drug benefit program for Medicare-eligible retirees.
Individual copay amounts may vary. Eligible patients with commercial insurance may pay as little as $15 per 30-count carton. Eligible cash paying patients may pay as little as $195 per 30-count carton. A maximum benefit limit may also apply. If the patient’s total out-of-pocket pharmacy bill exceeds the cap established by Sunovion, the patient will be responsible for the additional balance. Patients should confirm their out-of-pocket costs.
This program is not health insurance.
The amount of the benefit will not exceed your out-of-pocket expenses.
You must deduct the value of the savings received under this program from any reimbursement request submitted to your insurance plan, either directly or on your behalf.
Offer limited to one per person and may not be used with any other offer.
A minimum patient requirement for participation in the program is an activated Program ID number.
Only an original (no copies) or printout of the copay savings card must be presented to participating pharmacies.
For California and Massachusetts residents, benefits pursuant to this copay savings card will terminate automatically upon the introduction of a therapeutically equivalent product.
Offer valid only in the United States and Puerto Rico. Void where prohibited by law, taxed, or restricted.
Certain information related to your use of the copay savings card may be collected, analyzed, and shared with Sunovion for market research and other purposes related to assess Sunovion’s programs. Information shared with Sunovion will be aggregated and deidentified; it will be combined with other data related to other copay savings card redemptions and will not identify you.
This offer is not transferable and may not be sold, purchased or traded, or offered for sale, purchase, or trade. The offer has no cash value and may not be combined with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. The offer is intended to comply with all applicable laws and regulations, including, without limitation, the federal Anti-Kickback Statute, its implementing regulations, and agency guidance interpreting the federal Anti-Kickback Statute; the government pricing laws; and all other applicable laws.
To the Patient: You must present this copay savings card to the pharmacist along with your valid prescription to participate in this program. If you have any questions regarding your copay savings card eligibility or benefits, or if you wish to discontinue your participation, call KYNMOBI® KYNNECT. By using this copay savings card, you are certifying that you understand the enclosed program rules, regulations, and terms and conditions; you are eligible to participate in this program, including that you are not enrolled in any federal or state healthcare program; you have not submitted and will not submit a claim for reimbursement to, or otherwise seek payment from, any federal, state, or other governmental program for this prescription or where otherwise prohibited by law in your state; you will comply with any obligations or requirements imposed by your insurance plan; and you will otherwise comply with the terms mentioned herein.
To the Pharmacist: When you use this copay savings card, you are certifying that you have appropriately inquired regarding the patient’s insurance coverage and have not submitted and will not submit a claim for reimbursement to, or otherwise seek payment from, any federal or state healthcare program for this prescription.
Submit transaction to RxC Acquisition Company d/b/a RxCrossroads by McKesson using BIN #610524.
If primary commercial prescription exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
Acceptance of this copay savings card and your submission of claims to the program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.
The LoyaltyScript® Card is not valid for use with any other prescription drug discount or cash cards for KYNMOBI. Claims submitted utilizing the program are subject to audit or validation.
Patient is not eligible if prescriptions are paid in part or full by any state or federally funded healthcare programs, including but not limited to Medicare (including Medicare Advantage) or Medicaid (including managed Medicaid plans), Medigap, VA, DOD, TRICARE, or where prohibited by law. In addition, patients may not use the offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.
For questions regarding setup, claim transmission, patient eligibility, or other issues, call KYNMOBI® KYNNECT.
Sunovion reserves the right to rescind, revoke, or amend this offer at any time without notice.
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Authorization to Use and Disclose Personal Health Information and to Conduct Patient Support
I authorize my health plans, physicians, pharmacies, and other healthcare providers (collectively, my
“Providers”) to disclose my personal health information relating to my use of KYNMOBI (apomorphine HCl)
sublingual film, including my medical condition, treatment, care management, as well as the information
provided on this form (collectively, “Personal Health Information” or “PHI”), to Sunovion Pharmaceuticals
Inc. and its representatives, agents, and contractors that act on behalf of Sunovion (collectively,
“Sunovion”) so that Sunovion may use the information to enroll me in (including verifying my eligibility, as
applicable), facilitate my participation in, and administer KYNMOBI® KYNNECT and any other applicable
KYNMOBI
patient support programs that may be implemented by Sunovion (collectively, “KYNMOBI Patient Support”). As
part of this, Sunovion may use and disclose my Personal Health Information to:
Provide all KYNMOBI Patient Support for which I am eligible and have not opted out of and, where
applicable, as prescribed by my doctor or other healthcare provider;
Communicate with my Providers and other third parties as needed to facilitate the provision of KYNMOBI
Patient Support;
Contact me and my designated representative(s) regarding this form and my enrollment and participation
in KYNMOBI Patient Support, and provide me with related patient support communications, including by
mail, email, fax, telephone call, voicemail, text message (including calls and text messages made with
an automatic telephone-dialing system or a prerecorded voice) (up to 5 messages per week) (standard
message and data rates may apply; you may opt out at any time by replying “STOP”) and through messages
left for me that disclose that I take or may take KYNMOBI;
Provide me with educational information about KYNMOBI, in person, online, or by telephone, including
information and training regarding my use of KYNMOBI;
Monitor and evaluate KYNMOBI Patient Support for effectiveness, future program development, and other
administrative purposes; and
Monitor and report safety information about KYNMOBI, including in communications with the US Food and
Drug Administration and other government authorities.
I understand that once my Personal Health Information is disclosed to Sunovion under this authorization, it
is no longer protected by federal privacy laws and may be further disclosed by Sunovion. I understand that I
may refuse to sign this authorization and my healthcare provider(s) and health plan(s) will not condition my
treatment or benefits on whether I sign this Patient Authorization. I understand, however, that if I do not
sign this authorization, I may not be able to receive support through KYNMOBI® KYNNECT. I understand
that I
am entitled to a copy of this authorization. I understand that I may cancel this authorization at any time
by mailing a letter requesting such cancellation to Sunovion Pharmaceuticals Inc., 84 Waterford Drive,
Marlborough, MA 01752, but that this cancellation will not apply to any information already used or
disclosed pursuant to this authorization before the notice of the cancellation is received by Sunovion. This
authorization expires ten (10) years from the date of execution or upon such an earlier date as may be
mandated by state law, if applicable.
Thank you for registering at KYNMOBI!
We look forward to telling you more about KYNMOBI, a new medication to treat OFF episodes associated with Parkinson's disease, as it becomes available.
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A FULL-SERVICE RETAIL EXPERIENCE WITH WALGREENS
In-store pickup and mail* options for the Patient Starter Kit and 30-count cartons
Patient support service welcome letter and refill reminders
Benefits verification
Assistance with prior authorization requirements
Cash price option available for participating patients†
Price is $195 per 30-count carton‡
*Certain health plans do not cover, or participate in, this service. Check with the
health plan for further details. Walgreens Express is available on eligible prescriptions only. Most prescription orders
are available to be delivered to the patient’s home in 1–2 business days. Orders received by 4pm on
Friday, as well as requests made during the weekend, have an expected delivery day of Wednesday.
Prescriptions are not delivered on Sundays or holidays. Please note that while most prescriptions are
expected to be delivered in 1–2 business days, some deliveries may not be eligible for delivery due to
prescription type, delivery address, holidays, weather, or other delivery constraints.
†Participating patients agree not to submit claims to, or seek reimbursement from,
any third-party payer for the product; Medicare Part D patients must opt out of Part D coverage for the product for the
remainder of the plan year and agree not to count the purchase of the product toward their Medicare Part
D TrOOP. Participating patients agree to notify their Medicare Part D plan or other third party payor, as applicable, that they are participating in the offering.
‡Up to a maximum of 5 cartons per 30-day prescription.
