The New XEOMIN® (incobotulinumtoxinA)
Patient Savings Program

Effective for dates of service
on or after July 1, 2016

The existing XEOMIN® Copay Program is in effect for all dates of service on or before June 30, 2016. For information on the existing XEOMIN® Copay Program, please click here.

As part of our commitment to patients, Merz created the new XEOMIN® Patient Savings Program

  • The XEOMIN® Patient Savings Program is designed to support eligible patients with their actual out-of-pocket XEOMIN medication costs and related administration fees, up to a maximum amount of $3,500 per rolling 12-month period. The initial 12-month period begins with a patient’s acceptance into the Program (no earlier than July 1, 2016).
  • To be eligible, you must:
    • Be a clinically appropriate patient for therapeutic treatment with XEOMIN, as determined by your doctor
    • Be prescribed XEOMIN
    • Be at least 18 years of age
    • Have commercial insurance that covers XEOMIN medication costs
    • Not be enrolled in a state or federally funded prescription insurance program. This includes patients enrolled in Medicare, Medicare Advantage, Medicare Part D, Part B, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), the Department of Defense (DOD) or other federally funded or state funded health care programs, as well as patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government subsidized prescription drug benefit program for retirees.  If a patient is enrolled in a state or federally funded prescription insurance program, they are not eligible even if they elect to be processed as an uninsured (cash-paying) patient

Merz North America, Inc. reserves the right to modify or discontinue any and all aspects of the program at any time and without notice.

Further restrictions apply to eligibility and reimbursable expenses. Please see full terms and conditions below or call 1-888-4-XEOMIN (1-888-493-6646).

  • To obtain a XEOMIN® Patient Savings Program Application, you can:
    • Download an application here;
    • Speak to your health care provider; or
    • Call 1-888-4-XEOMIN (1-888-493-6646) between 8 am and 8 pm ET
  • For additional information, please download the XEOMIN® Patient Savings Program brochure, available here

How is the New XEOMIN® Patient Savings Program Different From the Previous XEOMIN® Co-pay Program?

The XEOMIN® Patient Savings Program At-a-Glance
FEATURE CURRENT PROGRAM NEW PROGRAM
Name XEOMIN® Co-pay Program XEOMIN® Patient Savings Program
Important Dates Ends: June 30, 2016 Begins: July 1, 2016
Benefits Reimbursement cap of $500 per treatment Maximum reimbursement of $3,500 per rolling 12-month period
Reimbursement Method Debit card Check
Enrollment Process Patient and provider have to sign the enrollment form Patients complete and sign enrollment form – NO provider signature required
Assignment of Benefits No option Patients have the option to:

  • Receive their reimbursement check directly (default), or
  • Assign their benefits to their provider for payment of their eligible XEOMIN®-related expenses

Answers to Your Questions about the New XEOMIN® Patient Savings Program

  • Are you enrolled in our current XEOMIN® Copay Program? If so, please click here for a list of Frequently Asked Questions about the transition to the new XEOMIN® Patient Savings Program
  • Would you like additional information about the new XEOMIN® Patient Savings Program? If so, please click here for a list of Frequently Asked Questions.

Eligibility, Terms and Conditions, and Program Limitations

From and after July 1, 2016, the Program covers eligible patients’ actual out-of-pocket XEOMIN medication costs and related administration fees up to a maximum amount of $3,500 per 12 month period beginning with patient’s acceptance into Program (no earlier than July 1, 2016).  The Program does not cover (a) office visit co-pays not directly associated with XEOMIN treatment; (b) facility co-pays not directly associated with XEOMIN treatment; or (c) any other costs excluded by the Program guidelines not specifically mentioned herein, which are subject to change.  Prior Program benefits and limitations apply up to and through June 30, 2016. 

Eligible patients must be clinically appropriate patients for therapeutic treatment with XEOMIN.  Patient must be prescribed XEOMIN. Eligible patients must be at least 18 years of age. 

This offer is valid only in the United States, excluding where it is otherwise prohibited by law.  Patients residing in the states of Massachusetts, Michigan, Rhode Island, and Minnesota are eligible for drug co-payment assistance only and are not eligible for other types of co-payment assistance, including but not limited to costs related to administration of the drug.

Eligible patients must have private commercial insurance that covers medication costs for XEOMIN, and acceptance of this offer must be consistent with the terms of that insurer’s drug benefit.  Eligible patients must not have coverage for XEOMIN through Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), the Department of Defense (DoD), or other federally funded or state funded healthcare programs.  Patients who move from commercial to federally funded or state funded insurance will no longer be eligible for the Program.  Proof required for receiving payment for out of pocket drug costs must be a valid explanation of benefits (EOB) or specialty pharmacy invoice, which must be submitted within 120 days after each treatment.

Patient may not seek reimbursement for value received from the Program from any third-party payers, including flexible spending accounts or healthcare savings accounts.  If at any time patient begins receiving coverage under any federal, state or government funded healthcare program, Patient is no longer eligible to participate in the Program and must call 1-888-4XEOMIN (1-888-493-6646) between 8 AM and 8 PM (EST) to stop participation.  Restrictions may apply.  This is not health insurance.

Patient and patient’s pharmacist are responsible for notifying insurance carriers or any other third party who pays for or reimburses any part of the prescription filled using the Program as may be required by the insurance carrier’s terms and conditions and applicable law.

Enrollment in the Program may be reviewed on an annual basis to determine continued eligibility. This offer may not be combined with any other coupon, discount, prescription savings card, free trial, or other offer for XEOMIN. 

This is a limited time offer, and Merz reserves the right to rescind, revoke, amend, or terminate this offer, or the program in its entirety, at any time, without notice.