MERZ CONNECT helps patients gain access to XEOMIN through a Patient Savings Program, Patient Assistance Program, and reimbursement support services

For Your Practice For Your Patients

For assistance, call 1-844-4MYMERZ
(1-844-469-6379) to reach a MERZ 
CONNECT specialist Monday through
Friday between 8am-8pm ET

Click Here for the MERZ CONNECT Provider Portal

MERZ CONNECT

The XEOMIN Patient Savings Program

Through MERZ CONNECT, your patients can access the XEOMIN Patient Savings Program, Patient Assistance Information, and other helpful resources

Download an electronic brochure here

 

 

 

 

Downloadable Forms

Patient Assistance Program Enrollment Form

This application should be completed by patients to determine if they are eligible for our Patient Assistance Program for uninsured
or underinsured patients.

Click Here to Download
Patient Savings Program Application

This application should be completed by patients to determine if they are eligible for our Patient Savings Program.

Click Here to Download

Patient Savings Program Eligibility Criteria

  • For commercially insured patients who qualify, Merz will reimburse out-of-pocket XEOMIN medication costs including co-pays, co-insurances, and deductibles and related administration fees up to $5,000 every 12 months*

  • Eligible commercially insured patients may pay as little as $0 out of pocket*†

  • Downloadble information and resources and related to symptoms and treatment

  • For residents of Massachusetts, Michigan, Minnesota, and Rhode Island, further restrictions apply

  • Submit claims within 120 days of date of service

*Restrictions apply to eligibility. Commercial Insurance required. Reimbursement limited to out-of-pocket XEOMIN medication costs and related administration fees. State limitations may apply. Please see Full Terms and Conditions at XEOMIN.com. Merz reserves the right to change XEOMIN Patient Savings Program Terms and Conditions, including the eligibility requirements, at any time. This is not health insurance.

Your patients may be required to pay upfront for their co-pay/co-insurance, as determined by their insurance coverage/policy and their healthcare provider’s co-pay collection practice.

For assistance, call 1-844-4MYMERZ (1-844-469-6379) to reach a MERZ CONNECT specialist Monday through Friday between 8am-8pm ET

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), Option 2.

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 $5,000 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.

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 1-888-4MY-MERZ (1-888-469-6379) between 8am-8pm ET 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.

XEOMIN Patient Assistance Program

Merz is proud to offer a Patient Assistance Program (PAP) that provides XEOMIN at no charge to eligible§ patients. XEOMIN is available at no charge to patients who:

  • Are uninsured or underinsured

  • Meet financial eligibility requirements (based on the Federal Poverty Guidelines)

    • Documentation of income is required

    • Eligibility will be determined prior to the first injection for both uninsured and underinsured patients

  • Are US residents

  • Are not eligible for Medicare, Medicaid, or any other government program

  • Meet specific medical and clinical criteria as determined by Merz

  • Re-establish eligibility every 12 months

  • For underinsured patients, the physician must follow the steps below before drug at no charge will be provided unless otherwise instructed by the XEOMIN reimbursement support staff:

  • File a clean claim with the payor

  • Receive a claim denial

  • Appeal the denial

  • Receive a denied appeal

  • Provide documentation of the denied appeal to Merz

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

§Criteria for the Patient Assistance Program (PAP) are established by Merz North America, Inc. Acceptance into the program does not entitle patients to receive assistance indefinitely. Eligibility must be re-established every twelve (12) months and assistance under the program may be terminated at any time. Changes in the status of the patient’s eligibility (such as changes in income and health coverage) should be reported to the Merz Neurosciences Patient Assistance Program within 30 days. Please see the Patient Assistance Program application for additional details.

Advocacy groups

American Dystonia Society Benign Essential Blepharospasm Research Foundation Dystonia Medical Research Foundation National Institute of Neurological Disorders and Stroke National Spasmodic Torticollis Association ST Dystonia, Inc.