XEOMIN® (incobotulinumtoxinA)
Patient Co-pay Program

This program is effective for all dates of service on or before June 30, 2016. For information on our new XEOMIN® Patient Savings Program (effective for dates of service on or after July 1, 2016) please click here.

As part of our commitment to patients, Merz created the XEOMIN Patient Co-pay Program

  • For patients who qualify, Merz will reimburse their eligible out-of-pocket costs for medication and related administration fees when they are enrolled in the program
  • Eligible patients may receive up to $500 reimbursement for out-of-pocket costs for co-pays per treatment session*
  • To be eligible, you must:
    • Be appropriate for XEOMIN treatment, as determined by your doctor
    • Be at least 18 years of age
    • Have commercial insurance that covers XEOMIN treatment costs
    • Not be enrolled in or eligible for Medicare, Medicare Advantage, Medicaid, Managed Medicaid, TRICARE (i.e., CHAMPUS), or other state or federally funded insurance plans

*A majority of eligible patients receive treatment with XEOMIN® (incobotulinumtoxinA) for no out-of-pocket costs. Based on actual program payments 01/2015-09/2015. Source: Covance Market Access Services, Inc. Patients with out-of-pocket expenses greater than $500 per treatment should expect to pay all out-of-pocket amounts over $500.

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 apply, call 1-888-4-XEOMIN (1-888-493-6646) between 8 am and 8 pm ET or speak to your health care provider.

You can also download an application here.

Out-of-Pocket Reimbursement in 5 Simple Steps

  1. 1.5.4_enroll_icon-02 1. ENROLL

    • To obtain a XEOMIN Patient Co-pay Program Application, you can:
      • Ask your health care provider
      • Visit XEOMIN.com and click on Co-pay Assistance Program
      • Call 1-888-493-6646 and select Option 2
    • Complete the application, and ask your physician to verify and sign.
    • Fax the completed form to 1-866-471-3005.
  2. 1.5.4_askDoc_icon 2. TALK TO YOUR DOCTOR

    • After your application is reviewed and it is determined that you meet the enrollment requirements for participation, you will receive a XEOMIN Patient Co-pay Program enrollment letter.
    • Discuss your treatment plan with your doctor to understand how the program works in the context of your treatment.
  3. 1.5.4_pay_icon 3. PAY AS USUAL

    • After your doctor administers XEOMIN, you should pay your co-pay/co-insurance as usual, in the amount determined by your insurance coverage/policy and your provider’s co-pay collection practice.
    • Your health care provider will submit your claim for reimbursement to your insurance company according to usual practice and procedure.
  4. 1.5.4_submit_icon 4. SUBMIT FORMS

    • Send your insurance company’s explanation of benefits (EOB) or specialty pharmacy shipment invoice via fax to 1-866-471-3005, or mail it to the following address, within 120 days of each treatment date, and the out-of-pocket charges on the EOB will be reviewed for eligibility:

      The XEOMIN Patient Co-pay Program
      PO Box 4280
      Gaithersburg, MD 20885-4280

  5. 1.5.4_reimburse_icon 5. RECEIVE REIMBURSEMENT

    • The first time you are reimbursed for eligible out-of-pocket costs to cover medication costs and related administration fees (up to $500 per treatment), a debit card will be mailed directly to your home loaded with the amount of your reimbursement. After that, funds for each subsequent eligible reimbursement will automatically be loaded onto that same debit card.
    • Out-of-pocket medication cost and related administration fees up to $500 per treatment are covered, but office visit co-pays and other co-pays not associated with XEOMIN treatment are not covered.

Frequently Asked Questions

What is the maximum co-pay amount that is reimbursed?

Your actual out-of-pocket payment for XEOMIN will be reimbursed for up to $500 per treatment session.

Does my doctor need to sign my enrollment form?

Yes. Both you and your doctor will need to sign the enrollment form to verify your treatment with XEOMIN.

Once I enroll, how long will it take to know if I am eligible?

Your eligibility will be determined within 2–3 business days of receiving your application. You will then be mailed an enrollment letter.

How long is the enrollment period? Will I need to re-enroll?

You will need to re-enroll and have your eligibility evaluated on an annual basis.

Can I participate in the program if I have specialty pharmacy benefits?

Yes! Patients who receive XEOMIN through a specialty pharmacy may enroll in the XEOMIN Patient Co-pay Program.

When should I send my EOB or specialty pharmacy shipment invoice?

Send these documents within 120 days of your treatment date for each treatment session. But remember: the sooner you send them, the sooner you will receive reimbursement for your eligible out-of-pocket costs.

Does the program pay for all of my costs related to XEOMIN?

The per-treatment cost limit for eligible out-of-pocket costs is $500 or the amount of your co-pay/co-insurance, whichever is less. The following eligible costs associated with XEOMIN treatment will be reimbursed directly to you, up to the above limit:

  • Any eligible costs specifically associated with your deductible
  • Any co-pay specifically associated with eligible costs
  • Any co-insurance costs specifically associated with eligible costs

The following costs are not eligible and will not be reimbursed:

  • Office visit co-pays not directly associated with XEOMIN treatment
  • Facility co-pays not directly associated with XEOMIN treatment
  • Any other costs excluded by the Co-pay Program guidelines not specifically mentioned above, which are subject to change

Terms and Conditions

This program covers eligible patients’ actual out-of-pocket treatment-related costs for XEOMIN (eg, drug co-pay) up to a maximum amount of $500.00 per treatment. Eligible patients must be clinically appropriate patients for treatment with XEOMIN.

Eligible patients must have commercial insurance that pays 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, Medicaid, TRICARE®, VA, or other federally funded health care programs or similar state pharmacy 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.

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 offer is valid only in the United States, excluding where it is otherwise prohibited by law. 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. Please refer to the XEOMIN Co-payment Program Application for complete terms and conditions.