SAPHRIS^® SAVINGS PROGRAM

If you are completing this form as a parent of or caregiver to someone receiving SAPHRIS^® treatment, please provide that person's information below.
Note: A parent or legal guardian must register patients under 18 years of age.

Activation

Patient's Date of Birth

Please enter in the correct format: MM/DD/YYYY

Patient's First Name

Please enter the patient's first name so we may contact you.

Patient's Last Name

Please enter the patient's last name so we may contact you.

Patient's ZIP Code

Please enter the patient's zip code.

Email Address *

Please ensure your email address is in the correct format: user@domain.com

Verify Email Address *

Please ensure your email address matches.

Please click here for full Prescribing Information, including Boxed Warning, for SAPHRIS.

*If patient is under age 18, please provide parent/caregiver email address.

If you are completing this form as a parent of or caregiver to someone receiving SAPHRIS^® treatment, please provide that person's information below.
Note: A parent or legal guardian must register patients under 18 years of age.

Activation

Is the patient a resident of the United States or Puerto Rico?

Yes

No

This field is required. Please make a selection.

This field is required. Please make a selection.

Does the patient have prescription drug insurance?

Yes

No

This field is required. Please make a selection.

This field is required. Please make a selection.

Is the patient enrolled in Medicare (including Medicare Advantage), Medicaid, or a VA/DoD health plan?

Yes

No

This field is required. Please make a selection.

Is the patient Medicare-eligible and enrolled in an employer-sponsored health plan or a prescription drug benefit program for retirees?

Yes

No

This field is required. Please make a selection.

Please click here for full Prescribing Information, including Boxed Warning, for SAPHRIS.

By activating your SAPHRIS Savings Card, you certify that all the responses you provided above are complete and accurate. You further certify that you understand that should you begin receiving prescription benefits from a Medicare, Medicaid, VA/DoD plan, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs that you will no longer be eligible to participate in this savings program. You also accept the Program Terms, Conditions, and Eligibility Criteria.

I agree to this certification and I accept the Program Terms, Conditions, and Eligibility Criteria available here or on back of card.

This field is required. Please make a selection.

^*This offer is valid only for patients with SAPHRIS prescriptions. Depending on insurance coverage, eligible patients pay as little as $15 for each of up to 12 prescription fills. Check with your pharmacist for your copay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. Offer not valid for patients enrolled in Medicare, Medicaid, or other federal or state healthcare programs. Please see back of card or click here for full Program Terms, Conditions, and Eligibility Criteria.

^†Please note that as of December 10, 2020, patients residing in or receiving treatment in California or Massachusetts are no longer eligible to participate in this program due to laws in those states regulating pharmaceutical patient savings programs. If you have any questions, please call 1.855.439.2832.

Please see full Prescribing Information, including Boxed Warning, at www.saphris.com.

Program Terms, Conditions, and Eligibility Criteria

This offer is valid only for patients 10 years of age or older and is good for use only with a valid prescription for SAPHRIS^® (asenapine) sublingual tablets 2.5 mg, 5 mg, and/or 10 mg at the time the prescription is filled by the pharmacist and dispensed to the patient.
Depending on your insurance coverage, most eligible patients may pay as little as $15 per 30-day supply for each of up to twelve (12) prescription fills. Check with your pharmacist for your copay discount. Maximum savings limit applies; patient out-of-pocket expense may vary.
This card is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients.
AbbVie reserves the right to rescind, revoke, or amend this offer without notice.
Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.
Void if prohibited by law, taxed, or restricted.
This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.
This card has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription.
This offer is not health insurance.
Subject to all other terms and conditions, the maximum annual benefit that may be available solely for the patient’s benefit under the copay assistance program is $1,200 per calendar year. The actual application and use of the benefit available under the copay assistance program may vary on a monthly, quarterly, and/or annual basis depending on each individual patient’s plan of insurance and other prescription drug costs.
By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

To learn about AbbVie’s privacy practices and your privacy choices, visit www.abbvie.com/privacy.html.

For questions about the program, including savings on mail-order prescriptions, please call 1-855-439-2832.

US-SPH-220003 12/22

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