Eligibility

Is this program for you?

To find out if you are eligible for the Novartis Oncology Universal Co-pay Program, simply answer the questions below. Please note that this information must be provided by you or your caregiver, and cannot be entered by a third party.

Limitations apply. Annual maximum of $15,000 per calendar year. See program terms and conditions below. This offer is not valid under Medicare, Medicaid, or any other federal or state program. Novartis reserves the right to rescind, revoke, or amend this program without notice.*

1.

I certify that I am over the age of 18 and that I am the patient or that I am the patient’s caregiver and have the patient’s consent to proceed with the enrollment of the Novartis Oncology Universal Co-Pay Program.

2.
Do you have commercial (also known as private) insurance?
3.
Are you enrolled in any state or federally funded programs, including but not limited to Medicare, Medicaid, VA, DoD, or Tricare?
4.
Are you paying cash for the full price of the prescription?
5.

Has your doctor prescribed the medicine for 1 of these conditions?

Please be truthful in your response. If the information you provide is inaccurate, it could affect your eligibility and you may not be able to receive co-pay assistance.

INDICATIONS

Sandostatin® LAR Depot (octreotide acetate for injectable suspension) is indicated for patients in whom initial treatment with immediate release Sandostatin® (octreotide acetate) Injection has been shown to be effective and tolerated for:

  • Long-term maintenance therapy in acromegalic patients who have had inadequate response to surgery and/or radiotherapy or for whom surgery and/or radiotherapy is not an option (the goal of treatment in acromegaly is to reduce GH and IGF-1 levels to normal).
  • Long-term treatment of the severe diarrhea and flushing episodes associated with metastatic carcinoid tumors.
  • Long-term treatment of the profuse watery diarrhea associated with VIP-secreting tumors.

In patients with carcinoid syndrome and VIPomas, the effect of Sandostatin Injection and Sandostatin LAR Depot on tumor size, rate of growth and development of metastases has not been determined.

IMPORTANT SAFETY INFORMATION

Warnings and Precautions: Treatment with Sandostatin LAR Depot may affect gallbladder function, sugar metabolism, thyroid and heart function, and nutritional absorption, which may require monitoring by your doctor.

Before taking Sandostatin LAR Depot: Tell your doctor if you have a history of heart disease or are taking other medications, including: cyclosporine, insulin, oral hypoglycemic agents, beta-blockers, and bromocriptine.

Common side effects: Most patients experience side effects at some time. Some common side effects that you may experience include:

  • Acromegaly: diarrhea, gallstones, abdominal pain, and flatulence.
  • Carcinoid tumors: back pain, fatigue, headache, abdominal pain, nausea, and dizziness.

Other information: Patients with carcinoid tumors and VIPomas should adhere closely to their scheduled return visits for reinjection in order to minimize exacerbation of symptoms. Patients with acromegaly should adhere to their return visit schedule to help assure steady control of GH and IGH-1 levels.

Please see full Prescribing Information.

*Terms and Conditions

  • This offer is valid only for those with commercial insurance and who have a valid prescription. This offer is not valid under Medicare, Medicaid, or any other federal or state program, for cash-paying patients, where product is not covered by patient’s commercial insurance, or where plan reimburses you for entire cost of your prescription drug. This offer is not valid where prohibited by law and is only valid in the United States and Puerto Rico.
  • This program is not health insurance. The offer may not be combined with any other rebate, coupon, or other offer(s).
  • The card you will receive is the property of Novartis Pharmaceuticals Corporation and must be returned upon request. Novartis reserves the right to rescind, revoke, or amend the program without notice.
  • You certify responsibility for complying with applicable limitations, if any, of any commercial insurance and reporting receipt of program rewards, if necessary, to any commercial insurer.
  • Present this offer and your insurance card along with a valid prescription at any participating pharmacy or through mail order.
  • Patients with commercial insurance will be responsible for up to the first $25 (specific offer varies by brand) and the program pays the remaining co-pay or coinsurance until you reach the yearly maximum of $15,000. After the program maximum, you will be responsible for the difference.
  • Questions should be directed to: 1-877-577-7756.
  • When you use this offer, you are certifying that you understand the program rules, regulations, and terms and conditions, and that you will disclose and report the use of this offer as may be required by your insurer.
  • You are not eligible if prescriptions are paid by any federal or state program, or where prohibited by law; and you will otherwise comply with the terms and conditions above.
  • This offer expires on December 31, 2018.
  • Additional terms and conditions may apply.