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Eligibility Criteria

To be eligible for the XEOMIN Patient Savings Program, you must:

• Be a clinically appropriate patient for therapeutic treatment with XEOMIN, as determined by your doctor
• Be prescribed XEOMIN
• Be at least 2 years of age and less than 65 years of age
• Have commercial insurance that covers XEOMIN medication costs
• Not be enrolled in a state-funded or federally funded prescription insurance program*
• For residents of Massachusetts and Rhode Island, further restrictions apply*
• Submit claims within 120 days of date of service

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 MERZ CONNECT guidelines not specifically mentioned above, which are subject to change
• In accordance with state law, the XEOMIN Patient Savings Program does not reimburse injection-related charges for patients residing in Massachusetts and Rhode Island

When using specialty pharmacy, click here.

*Subject to eligibility requirements. Commercial insurance required. Reimbursement limited to out-of-pocket XEOMIN medication costs and related administration fees.
Please see Full Terms and Conditions. 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.
^†You may be required to pay upfront for your co-pay/co-insurance, as determined by your insurance coverage and your healthcare provider's co-pay collection practice.

Terms and Conditions and Program Limitations

The Program covers eligible patients' actual out-of-pocket XEOMIN medication costs and, where permissible, related administration fees, up to a maximum amount of $5,000 annually beginning with patients' acceptance into the Program. The Program does not cover (a) office 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 here, 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 2 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 or Rhode Island 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.

Patients 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 1-855-4MERZTX (1-855-463-7989) between 8am–8pm ET to stop participation. Restrictions may apply. This is not health insurance.

Patient/Guardian and pharmacist are responsible for notifying insurance carriers or any other third party that 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 will 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.

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Patient Assistance Program Details

XEOMIN is available at no charge to eligible^‡ patients who:

• Are uninsured or underinsured
• Meet financial eligibility requirements (based on the Federal Poverty Guidelines)
  • Proof of income is required
  • Eligibility will be determined prior to the first injection for both uninsured and underinsured patients
• Are residents of the US, Puerto Rico, and other US territories
• Are not enrolled in Medicare, Medicaid, or any other government program
• Meet specific medical and clinical guidelines as determined by Merz
• Eligibility must be re-established every 12 months

If you are underinsured, there are certain steps your doctor must follow before you can receive XEOMIN at no charge. Talk to your doctor if you have any questions.

‡Criteria for the XEOMIN Patient Assistance Program are established by Merz Pharmaceuticals, LLC. Acceptance into the XEOMIN
Patient Assistance Program does not entitle patients to receive assistance indefinitely. Eligibility must be re-established every 12 months, and assistance under the XEOMIN
Patient Assistance Program may be terminated at any time. Please see the application for additional required eligibility information.