Ready to save?

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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 Savings 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 18 years old and a resident of the United States to activate a QBREXZA savings card. If you are between the ages of 9 and 18, your parent or legal guardian may be able to activate a savings card for you.

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

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

We’re sorry. Your child does not meet the eligibility requirements to participate in the QBREXZA Savings 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 Savings 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, including other vendors and affiliates, to provide benefits to you related to the activation of your QBREXZA Savings Card.

To continue, you must scroll through and agree to the entire terms and conditions below:

Terms and Conditions

The QBREXZA Savings 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, and the patient, or the patient’s parent or guardian, must be 18 years or older to receive Savings Card Program assistance.

Eligible patients with commercial prescription drug insurance coverage for QBREXZA may pay as little as $35. Eligible patients with commercial prescription drug insurance coverage that does not cover QBREXZA or eligible patients without prescription drug insurance may pay as little as $70. Individual patient savings are limited to $2,500 in maximum total savings for the term of the program.

This Savings Card Program is not health insurance or a benefit plan. Distribution or use of the Savings 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 Savings Card benefits 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 Savings Card Program, as may be required.

The Savings 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 Savings Card agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer.

The Savings Card will be accepted by participating pharmacies in the United States. To qualify for the benefits of this Savings Card Program, the patient may be required to pay out-of-pocket expenses for each prescription. This Savings 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 Savings 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 Savings Card as provided for under the applicable insurance or as otherwise required by contract or law. The Savings Card may not be sold, purchased, traded, or offered for sale, purchase, or trade. The Savings 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 July 1, 2019, this Savings Card will no longer be valid for residents of Massachusetts.

This Savings Card Program expires on 12/31/2019. Dermira reserves the right to rescind, revoke, amend, or terminate the program without notice at any time.

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

Step 2 of 3: Savings Card

Do you already have a Savings 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).

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 Savings Card is now active.

Please present your savings 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 off 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:

  • Call you to welcome you to therapy
  • Arrange delivery when your prescription is ready
  • Remind you when it’s time for a refill of QBREXZA

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

DOWNLOAD YOUR NEW CARD.

THIS REPLACES YOUR OLD CARD.

We were unable to validate the ID number entered. In an effort to avoid delaying your prescription savings, here is your new card.

Print or save your card

Check your benefit amount

Please present this card to your pharmacist to help you save on QBREXZA and pay as little as $35 per fill.

You will receive an email shortly confirming your enrollment.

Stay on top off 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:

  • Call you to welcome you to therapy
  • Arrange delivery when your prescription is ready
  • Remind you when it’s time for a refill of QBREXZA

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