SUTAB Med D

SUTAB® MEDICARE PART D ALTERNATIVE SAVINGS PROGRAM

If your Medicare prescription drug insurance does not cover SUTAB® or if your out-of-pocket costs exceed $40* for your Medicare Part D prescription of SUTAB®, Braintree Laboratories, a part of Sebela Pharmaceuticals may be able to help.

With this program, you no longer seek reimbursement for your SUTAB® prescription through your Medicare provider for out-of-pocket costs. Instead, you can use this Medicare Part D Alternative Savings Program. This program has no impact on your current insurance plan. Your Medicare Part D plan remains the same. To sign up for this savings program, just follow the 3 steps shown on the instructions that will be included with your card. If you have questions related to this program or need assistance activating the card, please call 844-721-1400.

*Terms, conditions, and limitations apply. Most eligible patients will pay as little as $40. Terms and Conditions below.

Please complete all fields and confirm your agreement with the statements below to download your card.

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Data related to your redemption of the SUTAB Medicare Part D Alternative Savings Program card may be collected, analyzed, and shared with Braintree Laboratories, Inc. or any of its affiliates for market research and other purposes related to assessing patient savings programs. Data shared will be aggregated and de-identified, meaning it will be combined with data related to other card redemptions and will not identify the patient.

PATIENT TERMS AND CONDITIONS
  • SUTAB Medicare Part D Alternative Savings Program card is valid for a cost reduction of a qualifying prescription of SUTAB for eligible patients.
  • SUTAB Medicare Part D Alternative Savings Program card can only be used by eligible patients one time for SUTAB. Subsequent SUTAB prescriptions will require a new card.
  • You must have prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
  • Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the SUTAB Medicare Part D Alternative Savings Program card must agree to the program terms in order to use this card.
  • You must agree to not seek reimbursement from your Medicare or Medicare Advantage prescription plan for your out-of-pocket costs for SUTAB purchased with this card.
  • You must also agree to not count the cost of SUTAB toward your deductible or true out-of-pocket cost.
  • You must notify your prescription plan that you have purchased SUTAB outside of your plan benefit by sending the attached letter to the your Medicare Part D provider.
  • You must purchase your prescription for SUTAB before 12/31/2022 with this card and not use your Medicare Part D benefit for SUTAB.
  • Program is not valid for any patients with commercial/private insurance, uninsured patients or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE.
  • No other purchase necessary.
  • SUTAB Medicare Part D Savings Program card is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount prescription savings card, or other offer not already associated with this offer.
  • SUTAB Medicare Part D Savings Program card is not insurance.
  • SUTAB Medicare Part D Savings Program card can be used at mail-order pharmacies.
  • SUTAB Medicare Part D Alternative Savings Program card can only be used by eligible United States residents at participating eligible retail pharmacies in the United States.
  • SUTAB Medicare Part D Alternative Savings Program card is the property of Braintree Laboratories, a part of Sebela Pharmaceuticals and must be turned in on request.
  • It is illegal to sell, purchase, trade, or counterfeit the SUTAB Medicare Part D Alternative Savings Program Card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
  • Braintree Laboratories, a part of Sebela Pharmaceuticals reserves the right to rescind, revoke or amend this offer at any time without notice.
  • Data related to your redemption of the SUTAB Medicare Part D Alternative Savings Program card may be collected, analyzed, and shared with Braintree Laboratories, Inc. and any of its affiliates, for market research and other purposes related to assessing patient savings programs. Data shared will be aggregated and de-identified, meaning it will be combined with data related to other card redemptions and will not identify the patient.