[VEM-lih-dee]

VEMLIDY Co-pay Coupon Program

INDICATION AND IMPORTANT SAFETY INFORMATION

The VEMLIDY Co-pay Coupon Program is here to help reduce your out-of-pocket costs

  • Eligible patients with commercial insurance may pay as low as a $0 co-pay for out-of-pocket costs for VEMLIDY, up to $5000 per year with no monthly limit, with the VEMLIDY Co-pay Coupon Program
  • If you are enrolled in a government healthcare program, such as Medicaid or Medicare Part D, you are not eligible. This includes when you are in the Medicare Part D coverage gap known as the "donut hole.”
As low as $0 co-pay

ENROLL HERE

For full terms and conditions click here.

Translation services are available in a variety of languages.
Please call 1-877-627-0415
today to get started

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Support Path®

IMPORTANT SAFETY INFORMATION

  • Do you need help understanding your health insurance and Gilead medication costs?

  • Even if you are not eligible for the Co-pay Coupon Program you can call Support Path at the number below to learn about other financial resources that may be available to assist with treatment and insurance costs

For more information call 1-855-7-MYPATH (1-855-769-7284)
Hours: Monday-Friday, 9 am to 8 pm, ET

Multilingual help is available.
Please notify one of our associates if non-English assistance is needed.
We will do our best to accommodate your language needs

You can enroll in the program online, or by downloading the form here. Terms and conditions apply.

ENROLL ONLINE

Continued below
More Important Safety Information

Enroll today and see if you are
eligible for savings!

IMPORTANT SAFETY INFORMATION (continued)

Commercially insured patients can start saving with the VEMLIDY Co-pay Coupon Program by using the form below to confirm your eligibility.

In order to receive the benefits of the program, it is important that you provide accurate information. When filling your prescription, be sure to have your Co-pay Coupon Program information available.

Translation services are available in a variety of languages—please call 1-877-627-0415 to request assistance.

PLEASE ANSWER ALL OF THE QUESTIONS BELOW:

We are sorry, the form requires some corrections.
Please complete the items highlighted in red.

Do you have a VEMLIDY Co-pay Coupon ID?

Yes

No

VEMLIDY Co-pay Coupon ID number:

The identifying information you provided is not valid for a new or existing card member. Please enter your information again. Select "No" if you do not have a card, or call 877-627-0415 to speak to a customer service representative.

Are you a current resident of the United States, Puerto Rico or a U.S. territory?

Yes

No

You are not eligible at this time. If you have questions, please call 877‑627‑0415.

Do you have commercial insurance? Commercial insurance includes prescription drug coverage offered by your employer or purchased by you directly.

Yes

No

You are not eligible at this time. If you have questions, please call 877‑627‑0415.

Are your prescriptions paid for in part or in full under any government healthcare prescription drug program, such as Medicaid, Medicare, VA, DoD or TRICARE? You are considered to be enrolled in Medicare Part D even if you are in the coverage gap (sometimes referred to as the "donut hole").

Yes

No

You are not eligible at this time. If you have questions, please call 877‑627‑0415.

If you begin receiving prescription drug benefits from any state, federal, or government-funded program at any time, you will no longer be eligible to use the VEMLIDY Co-pay Coupon. Do you acknowledge your agreement with this statement?

Yes

No

You are not eligible at this time. If you have questions, please call 877‑627‑0415.

First Name
Last Name
Date of Birth
Phone Number
Street Address
City
State
ZIP Code
Email:

I do not wish to provide an email/I do not have an email.

Does your insurance require you to use a mail-order pharmacy?

Yes

No

Language preference:

English

Traditional Chinese

Vietnamese

Korean

How long have you been on treatment?

Less than 1 month

1-3 months

3-6 months

6+ months

Not available or unknown

Would you like to receive additional information from Gilead?

Yes

No

I certify that I am at least 18 years of age and want to receive information from Gilead Sciences, Inc., and third parties working on behalf of Gilead. I agree that Gilead may use the information I provide to contact me and send me educational materials about products, disease education, and financial assistance, including the customer relationship marketing program. Gilead also may use my information for market research or to evaluate and improve the company's services and programs. I understand that I may stop receiving communications at any time by calling 1-877-627-0415 or clicking on the "unsubscribe" link at the bottom of the e-mails I receive from Gilead. I understand that Gilead and companies providing services to Gilead will not sell or rent my personally identifiable information. For more information about Gilead's privacy practices, please read our Privacy Policy.

Yes

No

Please confirm consent.

SUBMIT

VEMLIDY Co-pay Coupon Program Terms and Conditions

The VEMLIDY Co-pay Coupon Program will cover the out-of-pocket costs of a patient's VEMLIDY prescriptions up to a maximum of $5,000 per year. This maximum applies to all eligible Gilead medications for the program.

The VEMLIDY Co-pay Coupon ("Coupon") can be used only by eligible residents of the U.S., Puerto Rico, or U.S. territories at participating eligible retail, specialty, or mail-order pharmacies in the U.S., Puerto Rico, or U.S. territories. Product must originate in the U.S. or Puerto Rico, or U.S. territories. Persons must be 18 years or older to use the Coupon for themselves or a minor.

The Coupon is limited to one per person and is not transferable. No substitutions are permitted. This Coupon is available for each valid prescription. Patient may not be currently receiving free drug assistance through Gilead Sciences, Inc. (“Gilead”)’s patient assistance programs. The Coupon is not insurance and is not intended to substitute for insurance.

THE COUPON IS VALID ONLY FOR PATIENTS WITH COMMERCIAL INSURANCE AND IS NOT VALID FOR PRESCRIPTIONS THAT ARE ELIGIBLE TO BE REIMBURSED:

  • IN WHOLE OR PART, BY MEDICARE, MEDICAID OR A MEDICARE PART D PLAN, TRICARE, VA, DoD, PUERTO RICO GOVERNMENT HEALTH INSURANCE PLAN, OR ANY OTHER FEDERAL OR STATE-FUNDED HEALTHCARE BENEFIT PROGRAM (COLLECTIVELY, “GOVERNMENT PROGRAMS”); OR
  • BY COMMERCIAL PLANS OR OTHER HEALTH OR PHARMACY BENEFIT PROGRAMS THAT REIMBURSE FOR THE ENTIRE COST OF PRESCRIPTION DRUGS.

Medicare Part D enrollees who are in the prescription drug coverage gap (the “donut hole”) are not eligible for the co-pay Coupon. Patients who begin receiving prescription benefits from such Government Programs at any time will no longer be eligible to use the Coupon. Void where prohibited by law, taxed, or restricted.

Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the patient through the offer. Both patient and pharmacist are each individually responsible for reporting receipt of coupon benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the Coupon, as required.

It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the Coupon.

Certain information pertaining to use of the Coupon will be shared with Gilead, the sponsor of the program, and its affiliates. The information disclosed will include the date the prescription is filled, the number of pills or product dispensed by the pharmacists, and the amount of the patient's co-pay that will be paid for by using this Coupon. For more information, please see the Gilead Privacy Policy at www.gilead.com.

Gilead reserves the right to terminate, rescind, revoke, or modify this program at any time without notice.

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More Important Safety Information

INDICATION AND IMPORTANT SAFETY INFORMATION

What is VEMLIDY?

VEMLIDY is a prescription medicine used to treat chronic (long-lasting) hepatitis B virus (HBV) in adults with stable (compensated) liver disease.

  • VEMLIDY may lower the amount of HBV in your body.

  • VEMLIDY may improve the condition of your liver.

What is the most important information I should know about VEMLIDY?

VEMLIDY can cause serious side effects, including:

  • Worsening of hepatitis B virus (HBV) infection. Your HBV infection may get worse (flare-up) if you take VEMLIDY and then stop taking it. A “flare-up” is when your HBV infection suddenly returns in a worse way than before. Do not stop taking VEMLIDY without first talking to your healthcare provider, as they will need to monitor your health regularly to check your liver.

What should I tell my healthcare provider before taking VEMLIDY?

All of your medical conditions, including if you have end stage renal disease (ESRD) or HIV-1 infection. Your healthcare provider may test you for HIV infection before starting VEMLIDY. If you have HIV and only take VEMLIDY, the HIV virus may develop resistance and become harder to treat.

If you are pregnant or plan to become pregnant. It is not known if VEMLIDY will harm your unborn baby. Tell your healthcare provider if you become pregnant during treatment with VEMLIDY.

If you are breastfeeding or plan to breastfeed. It is not known if VEMLIDY passes into your breast milk. Talk with your healthcare provider about the best way to feed your baby.

Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some medicines may affect how VEMLIDY works. Keep a list of all your medicines and show it to your healthcare provider and pharmacist. Do not start a new medicine without telling your healthcare provider. Ask your healthcare provider if it is safe to take VEMLIDY with all of your other medicines.

What are the possible side effects of VEMLIDY?

  • New or worse kidney problems, including kidney failure. Your healthcare provider may do blood and urine tests to check your kidneys when starting and during treatment with VEMLIDY. Your healthcare provider may tell you to stop taking VEMLIDY if you develop new or worse kidney problems.

  • Too much lactic acid in your blood (lactic acidosis), which is a serious but rare medical emergency that can lead to death. Tell your healthcare provider right away if you get these symptoms: weakness or being more tired than usual, unusual muscle pain, being short of breath or fast breathing, stomach pain with nausea and vomiting, cold or blue hands and feet, feeling dizzy or lightheaded, or a fast or abnormal heartbeat.

  • Severe liver problems, which in rare cases can lead to death. Tell your healthcare provider right away if you get these symptoms: skin or the white part of your eyes turns yellow, dark “tea-colored” urine, light-colored stools, loss of appetite for several days or longer, nausea, or stomach-area pain.

The most common side effect of VEMLIDY is headache.

These are not all the possible side effects of VEMLIDY. Tell your healthcare provider if you have any side effect that bothers you or that does not go away.

Click here for Important Facts about VEMLIDY, including important warnings.

Tap for Indication and Important Safety Information, including important warnings on worsening of hepatitis B infection.

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YOUR CO-PAY COUPON!

Please provide your coupon when you refill
your prescription.

THE INFORMATION ON YOUR
CO-PAY COUPON IS REQUIRED
AND WILL NOT BE SAVED.

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your information for your pharmacist.

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