This site is intended for U.S. residents 18 years of age or older.

This site is intended for U.S. residents 18 years of age or older.

The Patient Support CONNECT program will cover the out-of-pocket costs for Daklinza (daclatasvir) for up to a maximum benefit of $5,000 per 28-day supply of 30 mg or 60 mg OR up to a maximum benefit of $10,000 per 28-day supply of 90 mg.

Support for Specialty Pharmacies
If you are a Specialty Pharmacy,
enroll a patient now.

Eligibility Requirements

You may be eligible for the Co-Pay Program if:

  1. You are insured by commercial insurance and your insurance coverage does not cover the full cost of your prescription, that is, you have a Co-Pay obligation;
  2. You do not have prescription insurance coverage through a state or federal healthcare program, including but not limited to Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA) or Department of Defense (DOD) programs; patients who move from commercial to a state or federal healthcare program will no longer be eligible;
  3. You are 18 years of age or older; and
  4. You are a resident of the United States or Puerto Rico.

Terms of Use

  1. Eligible patients who present an activated Co-Pay Card together with a valid prescription for Daklinza (daclatasvir):
    1. May pay $0 per 28-day supply, for up to a maximum benefit of $5,000 per 28-day supply of 30 mg or 60 mg OR
    2. May pay $0 per 28-day supply for up to a maximum benefit of $10,000 per 28-day supply of 90 mg.
    3. Other restrictions may apply.
      Patient is responsible for applicable taxes, if any.
  2. Offers not applicable to co-pays where the entire co-pay is covered by insurance.
  3. Patients, pharmacists, and healthcare prescriber cannot seek reimbursement from health insurance or any third party, for any part of the benefit received by the patient through this offer.
  4. Your acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value received as may be required by your insurance provider.
  5. The Co-Pay Card must be activated before use, and expires on December 31, 2017.
  6. Card is limited to 1 per patient for the life of the program and is not transferable. No substitutions are permissible, and offer cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription.
  7. The Co-Pay Card may not be sold, purchased, traded or counterfeited. Reproductions of this Co-Pay Card are void.
  8. Only valid in the United States and Puerto Rico; this offer is void where restricted or prohibited by law.
  9. No membership fees.
  10. This offer is not conditioned on any past, present or future purchase, including refills.
  11. The Co-Pay Card is not insurance.
  12. Bristol-Myers Squibb reserves the right to rescind, revoke or amend this offer at any time without notice.

The Co-Pay Card will be accepted only at participating pharmacies. For those customers using mail-order or any non-participating retail pharmacy, please call 855-396-2634 to request a patient rebate form, or go to www.patientrebateonline.com to download a form.

 

BY USING THIS CARD, YOU AND YOUR PHARMACIST AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.

 

To the Pharmacist: For processing assistance, please call McKesson Pharmacy Support at 855-396-2634, 8:00 AM–8:00 PM, Monday–Friday.

SUPPORT CENTER: 1-844-44CONNECT (1-844-442-6663), 9 A.M. - 5 P.M. EST, M-F    |    Request Support:

 

 

 
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