Privacy/Attestation
In order to participate in the VANFLYTA Co-Pay Program and receive a benefit, you must meet certain eligibility criteria. During the enrollment process for the VANFLYTA Co-Pay Program, you will be asked to provide personal information that may include your name, address, phone number, email address, date of birth, and information related to your insurance and treatment. This information is necessary in order for you to participate in this program. By enrolling in this program, you permit Daiichi Sankyo, Inc., and its vendors and affiliates, to provide benefits related to the use of your VANFLYTA virtual copay card and/or to activate use of your VANFLYTA Co-Pay Card, where applicable. You may choose to be contacted by mail, email, or phone. By enrolling in this program, you agree to allow Daiichi Sankyo, Inc. or its agents to contact you in the future about this program. Daiichi Sankyo, Inc.’s privacy policy can be found at: http://dsi.com/privacy-notice.
The VANFLYTA Co-Pay Program helps patients being treated with VANFLYTA, who have commercial insurance, with their prescription out of pocket responsibility. Under the program, qualifying patients may pay as little as $0 out of pocket per prescription. The program will cover the patient’s co-pay or coinsurance up to a maximum of $26,000 during a 12-month enrollment period. Please see the Terms and Conditions and Important Safety Information below.
Patients can enroll on this website or by calling Biologics at 1-800-850-4306 with any questions about eligibility and assistance with the enrollment process.
Patient must meet the following criteria to be eligible for the Co-Pay Program:
- The patient must have commercial insurance that covers VANFLYTA.
- Insurance does not cover the full cost, and the patient has a co-pay or coinsurance obligation.
- This offer is not valid for patients enrolled in Medicare, Medicaid, Medigap, Tricare, Veterans Affairs (VA), Department of Defense (DOD), or any state-funded programs, or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs.
- Patients may not use this offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or medical or prescription drug benefit program for retirees.
- Daiichi Sankyo, Inc. reserves the right to rescind, revoke, or amend this offer at any time, without notice.
- Offer good only in the USA, at participating pharmacies or healthcare providers.
- If the patient utilizes the entire $26,000 benefit throughout the 12 month calendar year period, the patient or healthcare provider may be able to request an exception due to financial hardship. These will be reviewed on a case by case basis. Approval will be determined by the Manager of Reimbursement Services of DSI.
- Void if prohibited by law, taxed, or restricted.
Program Benefits:
- Patient may be able to pay as little as $0 out of pocket per prescription up to the maximum annual copay program benefit $26,000 per calendar year.
- Additional Terms and Conditions of Program: Patients, pharmacists, and healthcare providers must not seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this program. Patients must not seek reimbursement from any health savings, flexible spending, or other healthcare reimbursement accounts for the amount of assistance received from the program. Patients may be required to notify their insurance company of any benefits received under the program. The program benefits are nontransferable. This offer is not conditioned on any past, present, or future purchase, including additional doses. The program is not insurance.