If you would like to join the ACIPHEX Program and receive a Monthly Savings Card, please read the information below and complete the required fields on the form. Or if you'd prefer, you can call 1-888-877-1201 and give us your information over the phone.
See card for details. Patients with prescription coverage and a co-pay of more than $20 are eligible to receive up to $55 off their ACIPHEX prescription, after a $20 out-of-pocket expense. Patients without prescription coverage may receive up to $55 off their ACIPHEX prescription.
Restrictions and Conditions of Use:
- Good toward the purchase of ACIPHEX prescriptions. No substitutions permitted.
- Not available to individuals insured by Medicare, Medicaid, TRICARE, or any similar state or federal healthcare programs.
- Monthly savings Card is void in Massachusetts, in California for patients with prescription coverage, and where prohibited by law.
- Benefit limited to one use per person for any 30-day period.
- Not valid through mail-order pharmacies.
- May not be accepted at all pharmacies.
- Not valid for ACIPHEX prescription reimbursed in full by any third-party payer.
- May not be combined with any other coupon, discount, prescription savings card, free trial, or other offer.
- Federal law prohibits the selling, purchasing, trading or counterfeiting of this Monthly Savings Card.
- Good only in the United States. Eisai Inc. reserves the right to rescind, revoke or amend this offer without notice at any time.
- Patients and pharmacies are responsible for disclosing to insurance carriers the redemption and value of the Card and complying with any other conditions imposed by insurance carriers or any third-party payers.
- The value of the Card is not contingent on any prior or future purchases. The Card is solely intended to provide up to $55 off any purchase of ACIPHEX. Use of the Card for any one purchase does not obligate the patient to make future purchases of ACIPHEX or any other product.
This card is not an insurance program.
No membership fees.
Offer expires 3/31/2021