The Hyaluronic Acid (HA)Designed for performance

Patient eligibility criteria for Patient Copay Relief Program

Eligibility Criteria, Terms and Conditions^*

• This offer is not valid for any other Ferring Pharmaceuticals Inc product. Mail, fax or submit online at euflexxa.patientsavings.com. No phone or emailed requests will be honored.
• Ferring Pharmaceuticals is not responsible for lost, late, damaged, misdirected, incomplete, or illegible submissions.
• The value of this refund may not exceed the amount of patient’s responsibility (copay) for the prescription. Maximum refund amount is $50 for series 1. Maximum refund is $75 for series 2.
• Offer limited to US residents with commercial Insurance who receive three (3) injections of EUFLEXXA.
• Refund claims must be received no later than 3 months after the last injection.
• Limit one refund per eligible patient.
• Ferring Pharmaceuticals reserves the right to cancel, modify, or rescind the program at any time.
• The patient responsibility (copay) for the injection administration and/or EUFLEXXA must be isolated on the claim. Office visits or other ancillary costs included in patient’s responsibility are excluded from refund amount.
• This offer is void where prohibited or restricted by law. Offer not valid for prescriptions and/or services reimbursed in whole or in part by any federal or state healthcare program, including, without limitation, Medicare, Medicaid, Department of Veterans Affairs healthcare program, TRICARE®, and any federal or state employee benefit program.
• Please retain copies of the materials you submit. All submissions become the property of a Ferring Pharmaceuticals contracted third-party vendor.
• Patient must fully complete and follow instructions as stated on the Euflexxa Copay Relief Form.
• Tampering with, altering, or falsifying payment information constitutes fraud.
• Please allow 10-14 business days for delivery of refund check. Refund check will be issued in US dollars.