Libtayo Surround Commercial Copay Program

Funded

About

The Libtayo Surround Commercial Copay Program offers substantial financial assistance for patients using the drug Libtayo. By leveraging the Libtayo Surround Commercial Copay Program, eligible patients with commercial insurance can pay as little as $0 for their Libtayo prescriptions. This program supports up to $25,000 in assistance per year for copay, coinsurance, and deductible costs. The Libtayo Surround Commercial Copay Program is a valuable resource for patients seeking to manage their treatment expenses effectively.

Insurance requirements: Commercially insured

Enrollment Forms

Enrollment Form

Benefits

•$25000 annual maximum benefit

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Must be 18 years of age or older

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Eligible, commercially insured patients may pay as little as $0 out of pocket for LIBTAYO, which includes any productspecific copay, coinsurance, and insurance deductibles—up to $25,000 in assistance per year

•The LIBTAYO Surround Copay Program does not cover non–productspecific expenses related to supplies, procedures, or physicianrelated services

•HCP and patients can enroll by completing the enrollment form and faxing to (8338538362) or by phone (patient and insurance details must be provided)

•Enrollment form is located here: https://www.libtayohcp.com/resources/pdf/englishenrollmentform.pdf

•HCP can also enroll patients and submit for their copay reimbursements at the LIBTAYO Surround Commercial Copay Program Portal (https://portal.trialcard.com/libtayo/)

•A LIBTAYO Surround Reimbursement Specialist will send a confirmation letter to office/patient upon approval of patient enrollment

•All reimbursement requests must be submitted within 120 days of the date of service

•For additional assistance, call us at 1.877.LIBTAYO (1.877.542.8296) Option 1, Monday–Friday, 8 am–8 pm Eastern time

Enrollment Forms

Enrollment Form