These Terms and Conditions govern the patient’s and the pharmacy’s participation in the MyVTAMA™ Program (the “Program”). Patients and pharmacies participating in the Program may be referred to herein, as “you” or “your.” The Program is offered by Organon LLC (“Organon”).
Program Details:
The Program offers the MyVTAMA™ Patient Savings Card (the “Card”) and is available to commercially insured patients with a valid prescription for VTAMA.
The Card provides savings on patient’s out-of-pocket expenses for up to a 90-day supply of VTAMA as described below. The maximum day supply limit may vary. A patient may use the Card once every 25 days, depending on when patient last received a 30-day supply of VTAMA.
Eligible commercially insured patients are responsible for paying out-of-pocket expenses and any amount that exceeds the benefits provided through the Card for each prescription. The Card’s benefits are not available for patient costs incurred prior to the date patient is determined to be eligible for the Program.
Patients may use the Card at any participating pharmacy located in the United States and Puerto Rico. The Card may not be combined with any other savings, discount, free trial, or other similar offers for the same prescription.
Patients must meet the eligibility criteria in these Terms and Conditions every time they use the Card. Limit one (1) Card per patient per use. The Card is not health insurance. The Card is not transferable and is void if reproduced. The Card has no cash value and will not be accepted outside of participating pharmacies in the United States and Puerto Rico.
Use of the Card may be subject to limitations imposed by state or federal law, or by your health insurer. The Card is not valid where prohibited by law or by your health insurer. The Card is void in California, and other states with similar laws, if a lower-cost FDA-designated therapeutically equivalent generic drug becomes available, or if the active ingredient in VTAMA becomes available without a prescription at a lower cost.
Patients who are enrolled in a government-run or government-sponsored healthcare plan with a pharmacy benefit are not eligible to participate in the Program or use the Card. Government-run or government-sponsored healthcare plans include, but are not limited to, Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange marketplace established by a state government or the federal government); Medicare; a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered); TRICARE; CHAMPUS; Puerto Rico Government Health Insurance Plan; or other state or federal medical or pharmaceutical benefit programs or pharmaceutical assistance programs (collectively, “Government Programs”).
Organon reserves the right to rescind, revoke, or amend these Terms and Conditions at any time, and to deny payment for noncompliance with these Terms and Conditions in its sole discretion.
Data related to your participation in the Program may be collected, analyzed, and shared with Organon, or its third-party vendors, for market research and other business purposes related to assessing its patient support programs. Data shared with Organon, or its third-party vendors, will be aggregated and de-identified, meaning it will not identify you specifically. For more information regarding Organon’s privacy practices and your privacy rights, please visit: www.organon.com/privacy/.
Patient Instructions:
You must present the Card to the pharmacist along with your prescription each time you fill your prescription. For questions about the Program or to discontinue participation in the Program, call Organon Savings Program customer support at 844-674-3200 8:00 AM to 7:00 PM ET, Monday to Friday).
By using the Card, you certify that you understand and agree to comply with the Program Terms and Conditions as set forth herein.
You may apply for the Card for yourself, if you are 18 years of age or older, or on behalf of a minor child 2 years of age or older (the “Child”). By using this Card, you acknowledge that you or the Child currently meet the following eligibility criteria:
- You/the Child have a valid prescription for VTAMA and that prescription is for an FDA-approved indication;
- You/the Child have commercial insurance;
- You/the Child are not enrolled in a Government Program;
- You are at least 18 years old;
- You/the Child reside in the United States or Puerto Rico.
Pharmacist Instructions:
By accepting/using this Card, you certify that you have not and will not submit a claim for reimbursement under any Government Program for the prescription.
- Submit transaction to Pharmacy Data Management Inc. (PDMI) using Bin #610020.
- Questions: Call PDMI at 1-800-800-7364.
- If commercial coverage exists, process it as primary and the Card as secondary (use COB segment).
- Acceptance/use of the Card is subject to the program terms and conditions of the Card administrator.
- Do not use/apply the Card in California, and other states with similar laws, if a lower-cost equivalent generic drug is available.
Pharmacy agrees that participation in the Program is voluntary and agrees to comply with the Terms of Condition of the Program and the terms and conditions of the Card administrator.
Pharmacy acknowledges Organon’s right to audit Pharmacy’s records in connection with Pharmacy’s participation in the Program and utilization of the Card. Pharmacy shall reimburse Organon for any payments made resulting from erroneous or improper utilization/application of the Card within 15 business days.
To report negative side effects: Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
