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Please answer a few simple questions to see if you’re eligible:

All fields are required unless otherwise noted.

Step 1 of 3: Eligibility

Please tell us who you are:

Are you 18 years of age or older and a resident of the United States?

As the parent or legal guardian, are you 18 years of age or older and a resident of the United States?

We’re sorry, a patient or a patient’s parent or guardian activating the QBREXZA Copay Card must be 18 years of age or older.

Are you enrolled in any state or federally funded health insurance program, including but not limited to Medicaid, Medicare, Medigap, TRICARE, the Department of Veterans Affairs healthcare program, or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program?

Is your child enrolled in any state or federally funded health insurance program, including but not limited to Medicaid, Medicare, Medigap, TRICARE, the Department of Veterans Affairs healthcare program, or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program?

We're sorry. You must be at least 18 years old and a resident of the United States to activate a QBREXZA Copay Card. If you are between the ages of 9 and 18, your parent or legal guardian may be able to activate a Copay Card for you.

We're sorry. In order to participate in the DermiraConnect QBREXZA Copay Card Program, the parent or legal guardian must be 18 years or older to activate a Copay Card.

We’re sorry. You currently do not meet the eligibility requirements to participate in the QBREXZA Copay Card program.

We’re sorry. Your child does not meet the eligibility requirements to participate in the QBREXZA Copay Card program.

If you have any questions, please call 1-877-DERMIRA (1-877-337-6472) to speak with a representative.

In order to participate in The DermiraConnect QBREXZA Copay Card Program, you must meet eligibility criteria. Before activating the card, it is important that you understand you will be asked to provide your personal information, and information related to your insurance. This information is necessary to permit Dermira, as well as other vendors and affiliates, to provide benefits to you related to the activation of your QBREXZA Copay Card.

To continue, you must scroll through and agree to the entire Terms and Conditions below:

Terms and Conditions

The QBREXZA Copay Card is valid ONLY for patients with commercial (private or non-governmental) insurance. Patients enrolled in Medicare, Medicaid, Medigap, TRICARE, the Department of Veterans Affairs healthcare program, or any other federal or state government-funded healthcare program (“Government Programs”) are not eligible. Patients who become enrolled in such Government Programs during their enrollment period will no longer be eligible for the program. Eligible patients must be residents of the United States, excluding territories, and the patient, or the patient’s parent or guardian, must be 18 years or older to receive Copay Card Program assistance.

The Copay Card should only be used in treatments that are in accordance with the QBREXZA prescribing information found at http://pi.dermira.com/QbrexzaPI.pdf

Eligible patients with commercial prescription drug insurance coverage for QBREXZA may pay as little as $35 per fill (30-day supply). Individual patient savings are limited to $200 per fill (30-day supply) and $2,500 in maximum total savings for the term of the program.

This Copay Card Program is not health insurance or a benefit plan. Distribution or use of the Copay Card does not obligate use or continuing use of any specific product or provider. Patient or guardian is responsible for reporting the receipt of all Copay Card savings or reimbursement received to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Copay Card Program, as may be required.

The Copay Card is not valid for medications the patient receives for free or that are eligible to be reimbursed by private insurance plans or other healthcare or pharmaceutical assistance programs that reimburse the patient in part or for the entire cost of his/her Dermira medication. Patient, guardian, pharmacist, prescriber, and any other person using the Copay Card agree not to seek reimbursement for all or any part of the savings received by the recipient through the offer.

The Copay Card will be accepted by participating pharmacies in the United States. To qualify for this Copay Card Program, the patient may be required to pay out-of-pocket expenses for each prescription. This Copay Card is only available with a valid prescription and cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription. Use of this Copay Card must be consistent with all relevant health insurance requirements and payer agreements. Participating pharmacies are obligated to inform third-party payers about the use of the Copay Card as provided for under the applicable insurance or as otherwise required by contract or law. The Copay Card may not be sold, purchased, traded, or offered for sale, purchase, or trade. The Copay Card is limited to one per person during this offer period and is not transferable. Void where prohibited by law, taxed, or restricted. Absent a change in Massachusetts law, effective December 31, 2019, this Copay Card will no longer be valid for residents of Massachusetts.

This Copay Card Program expires on December 31, 2019. Dermira reserves the right to rescind, revoke, amend, or terminate the program without notice at any time.

If you have questions or need additional support, call 1-877-DERMIRA (877-337-6472).

Step 2 of 3: Copay Card

Do you already have a Copay Card?

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Or call 1-877-DERMIRA (1-877-337-6472) to speak with a representative who can assist you with enrollment.

We're sorry. This card has already been activated.

Please call 1-877-DERMIRA (1-877-337-6472) to speak with a representative.

Step 3 of 3: Contact Information
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Patient Authorization and Consent

As further described below, I hereby authorize my providers and health plans to share my personal and medical information as described below with Dermira, the manufacturer of QBREXZA, and its contractors for limited purposes, all in accordance with this authorization.

Persons Authorized to Disclose My Information: My healthcare providers, including any pharmacy that fills my prescription for QBREXZA, and any health plans or Dermira programs that provide me healthcare benefits.

Information to Be Disclosed: Personal information about me (for example, my name, mailing address and insurance information) and my medical information (including information about my disease status) (together all such information is called my “health information” in this authorization).

Persons to Whom My Health Information May Be Disclosed: Dermira and its contractors and agents, including the third-party administrator responsible for the administration of DermiraConnect (collectively referred to in this authorization as “Dermira”).

Use of Information and Purposes for Which the Disclosures Are to Be Made: 1) to establish my eligibility for benefits from my health plan or other programs; 2) to provide financial assistance, support, and referral services, and communicating with my healthcare providers, including but not limited to, facilitating the provision of QBREXZA to me in certain limited situations; 3) to send me communications about the program or to evaluate the effectiveness of the program by telephone, mail, electronic means, or otherwise; and 4) for Dermira’s internal business purposes, including quality control, and enhancing surveys.

I understand that once my health information has been disclosed to Dermira, privacy laws may no longer restrict its use or disclosure; however, Dermira intends to protect my health information by using and disclosing it for the purposes described above and as required by law. I further understand that I may refuse to sign this authorization and that if I refuse, my eligibility for health plan benefits and treatment by my healthcare providers will not change, but I will not have access to services available through this program. I may cancel this authorization at any time by calling DermiraConnect at 1-877-337-6472. If I cancel, Dermira will stop using this authorization to access my health information after that cancellation data, but the cancellation will not affect any health information that has already been disclosed in reliance on this authorization before that cancellation date. I authorize DermiraConnect to leave a message, including the prescription name if I am unavailable. I am entitled to a copy of this signed authorization, which expires at the earlier of 10 (ten) years or other time period required under the state in which I reside, from the date it is signed by me.


Please complete the form before submitting.

Congratulations!

Your QBREXZA Copay Card is now active.

Please present your Copay Card to your pharmacist to help you save on QBREXZA and pay as little as $35.

You will shortly receive an email confirming your enrollment.

Print or save your card

Check your benefit amount

Stay on top of all things QBREXZA.

Now that you’ll be using QBREXZA, you can get useful information on product updates and other support tools.

Have your prescription mailed directly to you.

Ask your doctor to choose our pharmacy partner, Foundation Care, when he/she prescribes QBREXZA. Foundation Care is a full-service pharmacy that can fill your QBREXZA prescription and other prescribed medications via mail order.

To help get you started, Foundation Care will:

  • Help you get started on QBREXZA
  • Arrange a delivery
  • Remind you about upcoming refills

You can call Foundation Care with any questions: 1-877-337-7277 Monday to Friday, 8 am—6 pm, CST.