Copay Assistance Card for your
Sancuso prescriptions

Save up to $150 per month on Sancuso
after paying the first $20 per prescription*

Just follow these easy steps:

  1. Show this Copay Assistance Card and your valid prescription each time you pay for your prescription.
  2. Pay the initial $20 of your copay for each prescription of Sancuso then any remaining out-of-pocket cost will be reduced by up to $150 per month.*
  3. Save your Copay Assistance Card for repeated use. Maximum 4 patches per month. In no case will the monthly benefit exceed $150.

What you pay:

Out-of-Pocket Cost - Copay Card Pays = You Pay
$75   $55   $20
$170   $150   $20
$250   $150   $100

*Offer expires 01/31/2018. For qualifying patients only. Restrictions apply.
Program rules and eligibility provided on copay card. This coupon is not insurance.



1-800-SANCUSO
www.sancuso.com
Sancuso is a registered trademark of Kyowa Kirin, Inc.
©2017 Kyowa Kirin, Inc. All rights reserved.
Printed in U.S.A.   SAN-134-R2   February 2017