Co Pay Signup - PHYRAGO™

Patient information

First Name *

Last Name *

Date of Birth *

Gender *

Email Address *

Phone Number *

Address Line 1 *

Address Line 2

State *

City *

ZIP Code *

Insurance information

Insurance Company Name *

Insurance Plan Name/Type

Member ID / Policy Number

Group Number

BIN

PCN

Pharmacy Name

Healthcare provider information

Physician First Name *

Physician Last Name *

Clinic Name *

Phone Number *

Address Line 1 *

Address Line 2

State *

City *

ZIP Code *

Eligibility

I confirm that I am not currently enrolled in any government-funded health insurance programs such as Medicare, Medicaid, TRICARE, or similar federal/state-funded coverage.

I confirm that I am currently covered by a commercial (private) health insurance plan, not funded by any federal or state government program.

I acknowledge that the co-pay card cannot be used in combination with any other financial assistance programs, coupons, or discounts for this product.

Consent

Complete & sign the patient consent form

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*The PHYRAGO™ (dasatinib) tablets Co-Pay Assistance Program is available to eligible patients with commercial insurance. Patients who receive prescription coverage through any federal, state, or government-funded healthcare programs, including Medicare (Part D included), Medicaid, TRICARE, VA, or similar, are not eligible for this offer.

This program is not health insurance and may be subject to change or discontinuation at any time without notice. Additional restrictions, including monthly or annual caps, may apply. For full program Terms and Conditions, please call Cycle Vita at 888-360-8482 .

To learn more about our privacy practices, visit cyclepharma.com.