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*Offer covers commercially insured patients only.

Please note, this offer is not available for patients eligible for Medicare, Medicaid, or any other form of government insurance. Out-of-pocket costs may vary based on insurance coverage. Limitations apply. See full Terms and Conditions for eligibility restrictions.

Download Savings Card *Offer covers commercially insured patients only.

Savings Program Terms and Conditions

Terms, Conditions, and Eligibility Requirements: Eligible patients must have commercial prescription insurance with coverage for Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use. Uninsured and cash-paying patients are NOT eligible for this Program. Patients enrolled in any state or federally funded healthcare program, including but not limited to, Medicare, Medigap, Medicaid, VA, DOD, TRICARE, Puerto Rico Government Health Insurance Plan, Medicare-eligible patients enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees, are NOT eligible for this Program. Cash Discount Cards and other noninsurance plans are not valid as primary under this Program. This Program is restricted to residents of the United States and United States territories.

Patients may pay as little as $10 out of pocket for Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. Patient is responsible for costs above maximum benefit amounts. This Program is not insurance. Void if copied, transferred, purchased, altered, or traded and where prohibited and restricted by law. The Program is not transferable. No substitutions are permitted. The Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced. The Program benefit cannot be combined with any other financial assistance program, free trial, discount, prescription savings card, or other offer. This Program is managed by Mercalis on behalf of Teva Pharmaceuticals USA, Inc. Teva Pharmaceuticals USA, Inc. and its affiliates reserves the right to make eligibility determinations, to set Program benefit maximums, to monitor participation, and to change, rescind, revoke, or discontinue this Program at any time without notice. Limit one Program enrollment per individual. If you have any questions regarding this Program, your eligibility or benefits, or if you wish to discontinue your participation, please call 844-248-7949. Expiration Date: 12/31/2025.

The Copay Card is intended for the benefit of patients, not their insurance plans or other third parties. Patients whose commercial insurance plans do not apply Copay Card payments to satisfy patient out-of-pocket cost sharing amounts may not be eligible for the Copay Card. Similarly, patients whose commercial insurance plans require use of the Copay Card as a condition of the plan waiving some or all of otherwise applicable patient out-of-pocket cost sharing amounts may not be eligible for the Copay Card or have a reduced annual maximum program benefit. If you believe your commercial insurance plan may have such limitations, please call 844-248-7949.

Medical Claims:

• Eligible patients must have an out-of-pocket cost for Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use and be administered the product prior to the expiration date of the Program. The benefit available under the Program is valid for the eligible patient’s out-of-pocket cost for the product only. It is not valid for any other out-of-pocket costs (for example, office visit charges or medication administration charges, evaluations, or diagnostic testing) even if such costs are associated with the administration of Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use.
• A provider or patient is required to submit a copy of the Explanation of Benefits (EOB) from their commercial insurance plan detailing the patient's out-of-pocket costs for Teva's Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, and a copy of the insurance claim form (CMS-1500, UB04, or electronic equivalent) to receive reimbursement from the Copay Assistance Program. All claims must be submitted within 180 days of the EOB date.
• The Program may apply to eligible out-of-pocket costs incurred by the patient for Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use up to 180 days prior to the date an eligible patient is enrolled in the Program, subject to annual Program maximum and the applicable Terms and Conditions based on Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use administration date. Patient or provider may contact Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Program at 833-415-4355 for more information.

Valid only for Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use, National Drug Codes: 00480-9257-08, 00480-9259-08, and 00480-9262-08

To the Patient: By redeeming this Program, you acknowledge that you are an Eligible Patient and you understand and agree to comply with the terms and conditions of this Program.

This Program is for eligible Commercially Insured Patients only. Patients may pay as little as $10 out of pocket for Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. This Program must be presented along with your prescription for Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use and your primary insurance card to participate in this Program. Program not valid for Non-Insured/Cash-Paying Patients or where Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use is not covered by the primary insurance.

To the Pharmacist: When you apply this Program, you are certifying that Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use is being dispensed to an Eligible Patient in compliance with these terms and conditions and the Pharmacy has not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. For Commercially Insured Patients, please submit this claim to the primary Third-Party Payer first, then submit the balance due to Mercalis as a Secondary Payer COB (coordination of benefits) with patient responsibility and a valid Other Coverage Code (e.g., 08).

Reimbursement will be received from Mercalis. For questions regarding processing of pharmacy claims, please call the Help Desk at 844-248-7949.

To the Prescriber: By redeeming this Copay Card, you are certifying that you understand and agree to comply with the Terms and Conditions above. When you apply this offer, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. All claim submissions must include a copy of the Explanation of Benefits and a copy of the insurance claim form (CMS-1500, UB04, or electronic equivalent). Medical claims may be submitted by one of the below methods:

• Fax: 833-970-3587
• Mail to: Teva’s Octreotide Acetate for Injectable Suspension, for gluteal intramuscular use Savings Program, 2250 Perimeter Park Dr STE 300, Morrisville, NC 27560

Reimbursement will be received from Mercalis. For questions regarding processing of medical claims, please call the Help Desk at 833-415-4355.