$0 Co-pay Important Terms and Conditions
By participating in Vifor Pharma, Inc.’s $0 Co-pay Savings Program (”Co-pay
Program”) for VELTASSA, the patient acknowledges that, at the time of usage, they meet the eligibility
criteria and comply with the following terms and conditions.
The Co-pay Program is for commercially insured patients. Patients with prescription coverage through any
type of federal or state government-funded program are not eligible (eg, Medicare, Medicaid, TRICARE,
Veterans Administration [VA], Mi Salud).
The patient may pay as low as $0 per month for up to a 12-month period, and afterward renewal is required.
Annual maximum limits may apply. The Co-pay Program for VELTASSA is not insurance. Vifor Pharma, Inc.
reserves the right to rescind, revoke, or amend this program without notice. The patient must use the Co-pay
Program for a valid prescription of VELTASSA, and this cannot be combined with any other coupon, trial,
savings card, free drug assistance, or other offer.
Patient must live in the United States (including the District of Columbia, Puerto Rico, and the U.S.
Virgin Islands). If the patient is enrolled in Veltassa Konnect, patient is required to promptly inform
Veltassa Konnect of any change in insurance status during the course of enrollment.
The patient and participating pharmacy are each obligated to inform the insurance
plan of any benefit received under the Co-pay Program as required and may not participate if the Co-pay
Program conflicts with the plan’s policy. No party may seek reimbursement for any part of the benefit
received by patient under the Co-pay Program. The patient is responsible for applicable taxes. Limit one per
person; offer is non-transferable and void where prohibited by law or restricted.