QBREXZA Copay Card Terms and Conditions
The QBREXZA Copay Card is valid ONLY for patients with commercial (private or non-governmental) drug 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 $625 per fill (30-day supply) and $5,000 in maximum total savings per calendar year, January 1 – December 31. 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.
This Copay Card program renews annually on January 1.
Dermira, Inc., a wholly-owned subsidiary of Eli Lilly and Company, 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).
What is QBREXZA?
QBREXZA is a prescription medication used on the skin to treat excessive underarm sweating (primary axillary hyperhidrosis) in people 9 years of age and older.IMPORTANT SAFETY INFORMATION
What is the most important information I should know about QBREXZA?
Who should not use QBREXZA?
Do not use QBREXZA if you have certain medical conditions that can be made worse by taking an anticholinergic medicine such as glaucoma, severe ulcerative colitis (UC) or certain other serious bowel problems associated with UC, myasthenia gravis, and Sjogren’s syndrome.
What should I tell my healthcare provider before using QBREXZA?
- Tell your healthcare provider about all your medical conditions, including if you have prostate, bladder or kidney problems or problems passing urine; if you are pregnant or breastfeeding, or plan to become pregnant or breastfeed. It is not known if QBREXZA will harm your unborn baby or pass into breastmilk.
- Tell your healthcare provider and pharmacist about all the medicines you take, including prescription and over-the-counter medicines and especially any anticholinergic medicines.
What are the possible side effects of QBREXZA?
Serious side effects may include:
- New or worsened urinary retention: People who use QBREXZA may develop new or worse urinary retention. Urinary retention can result from a blockage in your bladder or a larger than normal prostate. Stop using QBREXZA and call your healthcare provider right away if you experience any of the following symptoms: difficulty urinating; urinating frequently; urinating in a weak stream or drips; full bladder or difficulty emptying your bladder.
- Problems with control of your body temperature: QBREXZA can cause you to have decreased sweating in areas other than the underarm leading to overheating and the development of heat illness when in hot or very warm temperatures. Stop using QBREXZA and call your healthcare provider right away if you experience any of the following symptoms: lack of sweating on your body; hot or red skin; decreased alertness or passing out; fast, weak pulse; fast, shallow breathing; increased body temperature.
- Blurred Vision: Stop using QBREXZA and call your healthcare provider if you develop blurred vision. Do not drive, operate machinery, or do hazardous work until your vision is clear.
The most common side effects of QBREXZA in clinical studies were dry mouth; dilation of the pupils; sore throat; skin redness, burning/stinging or itching in underarm area; headache; problems with urination; blurred vision; nasal, throat, eye, and skin dryness; and constipation. These are not all the possible side effects of QBREXZA. Call your healthcare provider for medical advice about side effects.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
QBREXZA is for use on the skin in the underarm only. Wash your hands right away after you apply QBREXZA and have thrown away the cloth.