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.
You may be eligible for the Co-Pay Program if:
- 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;
- 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;
- You are 18 years of age or older; and
- You are a resident of the United States or Puerto Rico.
- Eligible patients who present an activated Co-Pay Card together with a valid prescription for Daklinza™ (daclatasvir):
- 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
- May pay $0 per 28-day supply for up to a maximum benefit of $10,000 per 28-day supply of 90 mg.
- Other restrictions may apply.
Patient is responsible for applicable taxes, if any.
- Offers not applicable to co-pays where the entire co-pay is covered by insurance.
- 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.
- 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.
- The Co-Pay Card must be activated before use, and expires on December 31, 2017.
- 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.
- The Co-Pay Card may not be sold, purchased, traded or counterfeited. Reproductions of this Co-Pay Card are void.
- Only valid in the United States and Puerto Rico; this offer is void where restricted or prohibited by law.
- No membership fees.
- This offer is not conditioned on any past, present or future purchase, including refills.
- The Co-Pay Card is not insurance.
- 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.
To the Pharmacist: For processing assistance, please call McKesson Pharmacy Support at 855-396-2634, 8:00 AM–8:00 PM, Monday–Friday.