MONOFERRIC PATIENT SOLUTIONS® PROGRAM
Here to help you with your Monoferric® (ferric derisomaltose) injection treatment needs
When you are enrolled in the Monoferric Patient Solutions® Program, you will have access to tools that will support your iron deficiency anemia (IDA) treatment journey.
Financial support to help you gain access to Monoferric
We are committed to helping ensure Monoferric is available and affordable, so you can just focus on your treatment journey.
Monoferric Patient Solutions®
Copay Assistance Program
PATIENTS PAY AS LITTLE AS
The program allows patients to save on the cost of Monoferric throughout treatment.
Monoferric Patient Solutions® Copay Assistance Program Flashcard
To be eligible to participate in the Monoferric Patient Solutions® Copay Assistance Program, you must:
- Have commercial health insurance (i.e., health insurance offered through an employer; NOT Medicare, Medicare Advantage, Medicaid, TRICARE, or Veteran Affairs healthcare)
- Reside in the United States or Puerto Rico
- Be treated by a healthcare professional in the United States or Puerto Rico
- Be 18 years of age or older
- Be prescribed Monoferric for an on-label diagnosis
If you’re eligible to participate:
- You will receive savings of up to $2,000 per dose on out-of-pocket (OOP) expenses for Monoferric (i.e., to be applied to your deductible, copay, or coinsurance obligations)*
- Copay assistance may be applied retroactively to Monoferric costs that occurred within 120 days prior to the date of enrollment and you met all of the eligibility criteria at the time of your infusion
The Monoferric Patient Solutions®
Patient
Assistance Program
If you are uninsured or underinsured, the Monoferric Patient Solutions® Program is here to assist.
To be eligible to receive patient assistance, you must:
- Fall within the income guidelines†
- Be uninsured or underinsured (patients with claims covered, paid or reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state healthcare programs are not eligible for this program)
- Be 18 years or older
- Be prescribed Monoferric for an on‑label diagnosis
- Reside in the United States or Puerto Rico
*If IDA returns within the coverage period, you would receive an annual maximum savings on OOP expenses of up to $4,000. Additional restrictions apply.
Please see Full Terms and Conditions.
†Total household income is at or below 300% of the federal poverty level (FPL). Visit https://aspe.hhs.gov/poverty-guidelines, which lists the current FPL guidelines. Pharmacosmos Therapeutics Inc. and its authorized third-party agents will use the patient’s date of birth or social security number and/or additional demographic information as needed to access credit information and information derived from public and other sources to estimate income in conjunction with the eligibility determination process. As a soft credit inquiry, this option will not impact credit scores. Pharmacosmos Therapeutics Inc. and its authorized third-party agents reserve the right to ask for additional documents and information at any time. Note: Patients may retroactively qualify for assistance under the Patient Assistance Program if the patient’s healthcare provider submits an explanation of benefits (EOB) statement from the patient’s commercial insurance provider within 120 days of the date of service.
Additional resources to help you with treatment
Monoferric Patient Solutions® (MPS) Copay Assistance Program Terms and Conditions:
- Prescribed Monoferric for an on-label diagnosis
- This offer is valid for commercially insured patients only
- All information applicable to the MPS Copay Assistance Program requested on the enrollment form must be provided and all certifications must be signed. Forms that are modified or do not contain all the necessary information will not be eligible for benefits under the MPS Copay Assistance Program
- Depending on insurance coverage, eligible patients receive savings of up to $2,000 for Monoferric, up to a maximum savings limit of $4,000 annually. Patients must have out-of-pocket costs of over $0 to participate. Patient out-of-pocket expenses for Monoferric may vary
- This offer is not valid for patients enrolled in Medicare, Medicare Advantage, Medicaid, TRICARE, Veteran Affairs health care, a state prescription drug assistance program, the Government Health Insurance Plan available in Puerto Rico (formerly known as “La Reforma de Salud”) or any other federal or state healthcare programs
- Patients may not use the MPS Copay Assistance Program if the entire cost of the patient’s Monoferric prescription is reimbursable by their commercial insurance plan or other commercial health or pharmacy benefit programs
- The MPS Copay Assistance Program is valid for the patient’s out-of-pocket cost for Monoferric only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges) even if such costs are associated with the administration of Monoferric. Claim for Monoferric must be submitted by provider to patient’s private health insurance separately from other services and products
- The patient’s healthcare professional must submit an explanation of benefits (EOB) statement from the patient’s commercial insurance provider within 120 days of the date of service for the patient to receive assistance under the MPS Copay Assistance Program. No EOB may be submitted more than 90 days after the expiration or [termination date of the program], and the EOB must be for administration of Monoferric prior to the program expiration or termination date. The EOB must reflect the patient’s out-of-pocket cost for Monoferric and submission of the claim by the patient’s physician for the cost of the medication
- Patient enrollment is for the calendar year and each patient may reenroll in the MPS Copay Assistance Program in subsequent years, as needed
- The patient should not participate in the program if his/her insurer or health plan prohibits use of manufacturer coupons/copay assistance
- Patients must be 18 years of age or older to participate in the MPS Copay Assistance Program
- Offer good only in the USA, including Puerto Rico, at participating pharmacies or healthcare providers
- This patient savings under the MPS Copay Assistance Program may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer
- Void if prohibited by law, taxed, or restricted
- The funds provided for a specific patient case are not transferable. The selling, purchasing, trading, or counterfeiting of a patient’s unique account number is strictly prohibited
- This program is not health insurance
- This offer is not conditioned on any past or future purchases
- Data related to your receipt of financial assistance under the MPS Copay Assistance Program may be collected, analyzed, and shared with Pharmacosmos, for market research and other purposes related to assessing Pharmacosmos’s programs. Data shared with Pharmacosmos will be aggregated and deidentified; it will be combined with data related to other program use and will not identify you
- Pharmacosmos Therapeutics Inc. reserves the right to rescind, revoke, or amend this offer without notice
- By redeeming this assistance, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer
- Qualified patients receiving Monoferric will be allowed a 120-day retroactive enrollment period to receive benefits under the program rules