Lialda® (mesalamine) Pharmacy Savings Card

Get started with Lialda® (mesalamine) Prescription Savings

ELIGIBILITY VERIFICATION

First, we need to verify that you are eligible for the Lialda® Pharmacy Savings Card.
Please fill in the information below. Items marked with (*) are required.

*Date of birth

*Are you a resident of the United States?

YES

*Are you eligible for prescription drug benefits under Medicaid, a Medicare drug benefit plan, Tricare, or other federal or state health programs (including any state medical assistance program)?

YES

You are eligible for the Lialda Pharmacy Savings Card.

You're almost done. Please provide the following information and click "Submit" to get your card.

First name*

Last name*

E-mail address*

Address 1*

Address 2

City*

State*

Zip code*

We require this information so that we can send your permanent Pharmacy Savings Card and other important related information, and also to verify you as a patient.

Please send me convenient text alerts and refill reminders regarding my Lialda® (mesalamine) prescription. I understand that message and data rates may apply. I have reviewed and agree to the terms and conditions below.

Terms and Conditions and Additional Information

To help you stay on top of your Lialda prescription, we'll text confirmation of your out-of-pocket savings and refill reminders to your mobile phone. You can also receive your card ID information via text. We'll also text you to see if you want us to send refill requests directly to your pharmacy.

By providing your mobile phone number you are consenting to receive these periodic text messages. Shire’s partner(s) will use pharmacy claim information associated with your participation in the Lialda Pharmacy Savings Card Program in order to send you these messages. Message and data rates may apply. You may opt out of receiving messages by texting the keyword "STOP" at any time. For help, text the keyword “Help”. You represent that you are the authorized user of the wireless device you use to receive the messages and that you are authorized to approve any charges. Shire reserves the right to alter these terms and conditions or discontinue the messaging at any time and at its sole discretion, may add or delete a cellular carrier from this program at any time, without notice. Text messages you receive as part of this program are automated and your responses are not read by any person. This consent will be in effect until you opt out of receiving these communications from Shire. Please see Shire's Privacy Policy for additional information.

MOBILE PHONE NUMBER

By clicking “Submit” you are enrolling in the Lialda Pharmacy Savings Card Program and certifying that you are at least 18 years of age, are a resident of the US, and that you are ineligible for prescription drug benefits under Medicaid, a Medicare drug benefit plan, Tricare, or other federal or state health programs (including any state medical assistance program). If you are a commercially insured patient, you are responsible for reviewing the terms of your health insurance and/or prescription drug plan before using the Lialda Pharmacy Savings Card (a co-pay card), as some insurers may restrict your ability to use or require you to disclose your use of a pharmacy savings (co-pay) card.

Being a part of this program allows Shire to send you periodic communications. Shire respects your personal information. Please note that Shire may use this information to contact you for market research and other information believed to be of interest to you. Shire will also send you periodic reminder e-mails and other information about refilling your Lialda prescription. Shire’s partners will use your pharmacy claim information associated with your participation in the Lialda Pharmacy Savings Card Program in order to send you these communications. If, in the future, you no longer want to receive information and communications from Shire, please call the patient customer service line printed on the back of your Lialda Pharmacy Savings Card. The toll-free number is 1-866-250-8840. Personal information provided and collected in connection with this program will be kept confidential and will not be shared except in accordance with Shire's Privacy Policy. We encourage you to click here to view Shire's Privacy Policy.

If you have any questions about your eligibility or benefits, or if you no longer wish to participate in the Lialda Pharmacy Savings Card Program, call 1-866-250-8840.1-866-250-8840.

For helpful tips and resources, visit Lialda.com >

The Lialda Direct Program makes it easier to refill your prescription

Verify eligibility and enroll in the Lialda Direct Program to have your Lialda prescription shipped right to your home. If you have a Pharmacy Savings Card, your savings will be automatically applied. There is even an automatic refill option. If you're eligible, your doctor can enroll you, or you can sign up by calling CompleteCare Pharmacy at 1-844-LIALDA-RX (1-844-542-5327) between 8 AM and 6 PM ET, Monday through Friday.

You must have a valid Lialda prescription to enroll. Patients who are eligible for any government health care program are not eligible to participate in the Lialda Direct Program. Other restrictions apply. For additional information regarding the Lialda Direct Program, including eligibility, rules, and restrictions, please call CompleteCare Pharmacy at the number provided above.

With the Lialda Pharmacy Savings Card, eligible commercially insured patients pay the first $10 per monthly supply. After paying the first $10, the maximum savings is up to $500 for the first monthly fill and $120 per monthly fill for the remainder of 2017. Eligible cash-paying patients receive up to a $50 savings on the cost of their monthly prescription and will generally pay more than $10. Patients with questions, please call 1-866-250-8840.

Eligibility, rules, and restrictions: Card must be activated before use and is only valid on one prescription per month at participating US pharmacies. Patient must be 18 years or older. Offer not valid for prescriptions covered by or submitted for reimbursement under Medicaid, a Medicare drug benefit plan, Tricare, or other federal or state health programs (including any state medical assistance program). By using this offer, you certify that you are ineligible for prescription drug benefits under any such program and that you will comply with all terms of your health insurance contract requiring payer notification of the existence and/or value of this offer. The parties reserve the right to amend or end this program at any time. Card not valid if reproduced and may not be redeemed for cash. Void where prohibited by law. This offer is not transferable and is limited to one offer per person. Card expires 12/31/17. Other restrictions may apply.

Mail-order pharmacy patients

Most mail-order pharmacies require patients to send a photocopy of their Lialda Pharmacy Savings Card along with their prescription. If the mail-order pharmacy does not accept the Lialda Pharmacy Savings Card, please call 1-866-250-88401-866-250-8840 for assistance with reimbursement. Valid only if the patient’s out-of-pocket costs are more than the discount provided by the program.

The Lialda Direct Program makes it easier to refill your prescription

You must have a valid Lialda prescription to enroll. Patients who are eligible for any government health care program are not eligible to participate in the Lialda Direct Program. Other restrictions apply. For additional information regarding the Lialda Direct Program, including eligibility, rules, and restrictions, please call CompleteCare Pharmacy at the number provided above.

Lialda^® is a registered trademark of Nogra Pharma Ltd., Ireland.
SHIRE and the Shire Logo are trademarks or registered trademarks of Shire Pharmaceutical Holdings Ireland Limited or its affiliates.

1-800-828-2088 www.Lialda.com

Lexington, MA 02421

S13451 12/16

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