Prescription Forms for ABILIFY MYCITE® (aripiprazole tablets with sensor)

Prescribing an ABILIFY MYCITE^® Kit

Prescription Form
For patients who need to have an ABILIFY MYCITE Kit prescription filled and/or administered.

New Patient Set-up Checklist
Gives you all the information you need to set up your patients with the ABILIFY MYCITE^® System.

Need more information about the ABILIFY MYCITE System?

To learn more about how the ABILIFY MYCITE System works, including setup and how to get your patients started, go to ABILIFYMYCITEhcp.com.

Details and Eligibility

For patients:

In order to redeem this offer you must have a valid prescription for ABILIFY MAINTENA^® (aripiprazole). This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria (not a member of a federal, state, or government insurance program) and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the offer should call 1-888-591-9812.

Pharmacist:

When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription. As a condition of payment, you certify that you are in compliance with all program rules, terms, and conditions, as well as with any obligations to provide notice of your participation in this program to third-party payers as required by law, contract, or otherwise.

Submit the claim to the primary Third Party Payer first, then submit the balance due to Therapy First Plus as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 8). Eligible patients are responsible for as little as $10, with up to $8,000 in annual savings. A valid Prescriber ID# is required on the prescription. Reimbursement will be received from Therapy First Plus. For any questions regarding Therapy First Plus online processing, please call the Help Desk at 1-800-422-5604.

For healthcare professionals:

When you apply for this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

Restrictions:

This offer is only valid in the United States and Puerto Rico and is not transferable. Patients are not eligible if they are under 18 years of age or are covered in whole or in part by any state program or federal healthcare program, including, but not limited to, Medicare or Medicaid (including Medicaid managed care), Medigap, VA, DOD, or TRICARE. Offer void where prohibited by law, taxed, or restricted. Other restrictions may apply. This program is not health insurance. Otsuka America Pharmaceutical, Inc. has the right to rescind, revoke, or amend this program at any time without notice. Your participation in this program confirms that this offer is consistent with your insurance coverage and that you will report the value received if required by your insurance provider. When you use this card, you are certifying that you understand and will comply with the program rules, terms, and conditions. Program managed by PSKW, LLC on behalf of Otsuka America Pharmaceutical, Inc. Offer not valid for cash-paying patients OR where drug is not covered by the primary insurance.

Please see U.S. FULL PRESCRIBING INFORMATION, including BOXED WARNING, AND MEDICATION GUIDE for ABILIFY MAINTENA.

ABILIFY MYCITE®

(aripiprazole tablets with sensor)

Prescribing an ABILIFY MYCITE® Kit