BIN#:   004682
PCN#:   CN
GRP#:   EC53001015
ID#:   58674297799

Copay Assistance Card for your Sancuso prescriptions

Save up to $300 per patch on Sancuso after paying the first $20 per prescription
(maximum $1200 per month for 4 or more patches)*

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 and any remaining out-of-pocket cost will be reduced by $300 for 1 patch to a maximum of $1200 per month for 4 or more patches.*
3. Save your Copay Assistance Card – this card can be used multiple times up to 48 patches per patient. In no case, will the monthly benefit exceed $300 for 1 patch, $600 for 2 patches, $900 for 3 patches or $1200 for 4 or more patches.

*Offer expires 01/31/2019. For qualifying patients only. Restrictions apply.
Program rules and eligibility provided on copay card. This coupon is not insurance.

Sancuso is a registered trademark of Kyowa Kirin, Inc.
©2017 Kyowa Kirin, Inc. All rights reserved.
Printed in U.S.A.   SAN-134-R3   September 2017