Terms, Conditions, and Eligibility Requirements:
To the Patient:
CIMplicity® Savings (the “Program”) provides CIMZIA®
(certolizumab pegol) Prefilled Syringe or Lyophilized Powder to eligible patients for
as little as $0 per dose. Eligible patients must have commercial insurance coverage
and a valid prescription for CIMZIA Prefilled Syringe or Lyophilized Powder consistent
with FDA-approved product labeling. The Program is not valid (1) for prescriptions
that are reimbursed, in whole or in part, under Medicare (including Medicare Part D), Medicaid, or any other federal- or state-funded healthcare programs (including but
not limited to any state prescription drug assistance programs and the Government
Health Insurance Plan available in Puerto Rico), (2) where a patient’s commercial
insurance plan reimburses for the entire cost of the drug, (3) for uninsured or cash
paying patients, (4) where the product is not covered by patient’s insurance, or
(5) where otherwise prohibited by law. Product shall be dispensed pursuant to
Program rules and federal and state laws. The value of the Program is exclusively
for the benefit of patients and is intended to be credited in full toward patient out-of-
pocket obligations and maximums, including applicable co-payments, coinsurance
and deductibles. Patient may not seek reimbursement for the value received from
this Program from other parties, including any health insurance program or plan,
government healthcare program, flexible spending account, or healthcare savings
account. Patient is responsible for complying with any applicable limitations and
requirements of their health plan related to the use of the Program. Valid only in the
U.S. and Puerto Rico. This Program is not health insurance. Proof of purchase may be
required. This Program is not transferable and cannot be combined with any other
savings, free trial, or similar offer. UCB, Inc. reserves the right to amend or end this
Program at any time without notice. Subject to the prior sentence, this Program expires
at 11:59 p.m. on December 31. Patients that meet the above requirements may
re-enroll in the Program each year.
If you are uninsured, other financial assistance may be available. Call UCBCares® toll free at 1-844-599-CARE (2273) for more information. UCB, Inc., is not liable for unintended or unauthorized use of the CIMplicity Savings Card if it is lost or stolen.
To the Pharmacist:
When you apply this offer, you are certifying that this patient meets the outlined eligibility requirements, including that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription.