Co-Pay Assistance
The Xeomin® Patient Co-payment Program
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1. Enroll
- Patient initiates the enrollment process by calling 1-888-4-XEOMIN (1-888-493-6646) or by faxing a XEOMIN® Patient Co-payment Program Application to 866-471-3005. Physician assists the patient in the enrollment process by verifying some of the required enrollment information (see Enrollment Form).
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2. Discuss
- After the patient’s application is reviewed and the program determines that he or she satisfies the enrollment requirements for participation in the Co-pay Program, the patient will receive a XEOMIN® Patient Co-payment Program Enrollment Letter. Patient should discuss treatment plan with his or her physician.
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3. Treatment
- Healthcare Provider administers XEOMIN® injection and submits claim for reimbursement for XEOMIN® to the patient’s insurance company according to the provider’s usual practice and procedure. The patient will pay his or her co-pay/coinsurance to the physician in an amount as determined by the patient’s insurance coverage/policy and the Provider’s usual co-payment collection practices.
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4. Submit
- Patient sends Explanation of Benefits (EOB) or specialty pharmacy shipment invoice to XEOMIN® Patient Co-payment Program by faxing to 866-471-3005 or mailing to The XEOMIN® Patient Co-payment Program: PO Box 4280 Gaithersburg, MD 20885-4280 within 90 days of injection date.
A Co-pay Program debit MasterCard, loaded with funds in the amount of the patient’s eligible out of pocket costs as determined by the Co-payment Program guidelines, is mailed directly to the patient’s home. To be eligible, a patient's out of pocket costs must be associated with XEOMIN treatment for FDA approved indications and may include the cost of XEOMIN, associated guidance therapy, and related administration fees (“eligible costs”). Patients may use the card wherever debit MasterCards are accepted, including healthcare providers.
The program terms and conditions limit the amount of out-of-pocket costs that can be reimbursed to patients per XEOMIN® treatment.
The per treatment out-of-pocket cost limit is $500 or the amount of the patient's Co-pay/coinsurance, whichever is less. The following eligible costs associated with XEOMIN treatment will be reimbursable directly to the patient up to the above limit:
- Any eligible costs specifically associated to the patient's deductible
- Any co-pay specifically associated to eligible costs
- Any coinsurance costs specifically associated to eligible costs
The following costs are not eligible and will not be reimbursable:
- Office visit co-pays not directly associated with the Xeomin treatment
- Facility co-pays not directly associated with the Xeomin treatment
- Any other costs excluded by the Co-pay Program guidelines (e.g. not specifically mentioned above), which are subject to change.
The patient must re-enroll in the Program on an annual basis, and a re-enrollment form will be sent to the patient by the Program. Patients must continue to meet the Program's eligibility requirements to participate in the Co-pay Program. Patients who are eligible for any federal or state funded healthcare program, including Medicare, Medicaid, and CHAMPUS, or who are residents of Massachusetts are not eligible for participation in the Program. If required, the patient is responsible for reporting to their private insurer if they receive a card based-coupon. Offer only good in the USA. Not valid where prohibited by law, taxed or restricted. Please see the complete eligibility requirements on the Enrollment Application. The Program and the eligibility requirements are subject to change at the discretion of Merz Pharmaceuticals, LLC and may be discontinued at any time without notice. No prior or future purchase required for participation.
This is not an insurance program.
