The XEOMIN® Patient Savings Program

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

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:

Eligibility, Terms and Conditions, and Program Limitations

The program covers eligible patients’ actual out-of-pocket XEOMIN medication costs and related administration fees up to a maximum amount of $5000 per 12-month period beginning with patient’s acceptance into the Program. 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.

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 and less than 65 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.