To start your enrollment into the ORSERDU Co-pay Card Program,
please answer the following questions:

Terms and Conditions:

By using this co-pay card or by mailing in this rebate, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:

• Patients are not eligible to use this card or participate in the rebate program if they are using a state or federally funded insurance program to pay for their medication, including but not limited to Medicare, Medicaid, TRICARE, Veterans Affairs health care, a state prescription drug assistance program, or the Government Health Insurance Plan available in Puerto Rico.
• Patient must have private insurance. Offer is not valid for cash-paying patients.
• With this card, eligible patients will pay a $0 co-pay per eligible monthly prescription, subject to a maximum amount of $25,000 per product per calendar year and a per fill maximum of $9,500 . The amount of any benefit is the difference between your co-pay and $0 . After the annual maximum of $25,000 per product is reached, you will be responsible for the remaining monthly out-of-pocket costs.
• This co-pay card and rebate are not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private insurance plan or other private health or pharmacy benefit programs.
• You must deduct the value of this co-pay card or value received under this rebate from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf.
• This co-pay card and rebate are not valid where prohibited by law.
• Third-party discount cards and other non-insurance plans are not valid as primary payers under this offer. This offer and rebate cannot be combined with any other savings, free trial, or similar offer for the specified prescription.
• Card will be accepted only at participating pharmacies.
• This card and rebate are not health insurance.
• Offer good only in the U.S. and Puerto Rico.
• Card is limited to 1 per person during this offering period and is not transferable.
• No other purchase is necessary.
• Data related to your redemption of the co-pay card and/or rebate may be collected, analyzed, and shared with Stemline for market research and other purposes related to assessing Stemline’s programs. Data shared with Stemline will be aggregated and de-identified; it will be combined with data related to other co-pay card redemptions and will not identify you.
• Stemline reserves the right to rescind, revoke, or amend this offer and rebate program without notice.
• For questions, call 1-800-519-2140.
• If your pharmacy does not participate in the co-pay program, you may be able to submit a request for a rebate in connection with this offer:
  • Mail a copy of the patient’s original pharmacy receipt indicating patient name, name of medication purchased, price paid, and date purchased, accompanying your prescription, as proof of purchase, along with a copy of the patient’s Stemline Co-Pay Savings Card, to: StemlineARC Co-Pay Savings Program, Attn: Claims Processing Department, 77 Corporate Drive, Bridgewater, NJ 08807. Receipt will not be returned.
    • The patient will receive a maximum of $25,000 per product per calendar year and a per fill maximum of $9,500 or the amount of the co-pay paid, whichever is less.
    • Rebate will be mailed to patients approximately 6 to 8 weeks after receipt of required documentation or earlier, as required by law.