KLISYRI® (tirbanibulin) Cash-Only Program Terms & Conditions For Eligible, Insured Medicare Part D Members
By agreeing to purchase Klisyri® (tirbanibulin) ointment using this cash-pay offer, you are certifying that you have reviewed these Terms and Conditions, that you are an eligible patient, and that you understand and agree to comply with the program's Terms and Conditions and participation requirements at the time of each use.
Eligible patients must have a valid prescription for Klisyri® who have insurance coverage through Medicare Part D, but whose Part D health plan does not cover Klisyri® or who have a cost sharing obligation for their Klisyri® prescription that exceeds $100. Eligible patients will purchase Klisyri® entirely out-of-pocket at a discounted cash-pay price of $95 for one Klisyri® prescription.
This offer cannot be combined with any coupon, free trial, discount, prescription savings card, or other offer not associated with this offer. No other purchase is necessary. This cash-pay offer is restricted to residents of the United States and United States territories, and only available at participating pharmacies. This cash-pay offer is not insurance.
By using this offer, you agree and understand that this cash-pay offer is unrelated to any insurance coverage you might have for prescription drugs, and this offer does not provide assistance with any copay or deductible obligations you may have with your insurance provider. You agree to comply with any obligations you may have to your insurance provider, including your Part D plan.
You agree that you have not submitted and will not submit a claim for reimbursement under any insurance for the cost of the prescription for which you are using this cash-pay offer, and that you will not count the cost of Klisyri® toward your deductible. Additionally, you agree that you will not seek true out-of-pocket (TrOOP) credit under the Medicare Part D program for any portion of the cost of Klisyri®.
You agree that you will not seek reimbursement from your Medicare coverage for any Klisyri® prescriptions for the remainder of the current coverage year, including for your current prescription and any additional prescriptions or refills for Klisyri®. You also agree that you will provide notice to your Medicare Part D Plan that you are participating in the Klisyri® Cash-Only Program brought to you by Almirall, LLC.
Data related to an eligible patient's participation in the cash-pay program may be collected, analyzed, and shared with Almirall, LLC for market research and other purposes related to assessing the program. Data shared with Almirall, LLC will be aggregated and deidentified, meaning it will not identify specific patients.
Almirall, LLC reserves the right to rescind, revoke, or amend this offer at any time without notice. Void where prohibited by law, taxed, or restricted. If you have any questions regarding this program or your eligibility, please contact Almirall, LLC.
To the Pharmacist
When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental program, or under any commercial or other health insurer, 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 of this program.
To access the Klisyri® cash-pay offer, request through InfinityRx BIN 025706 as the primary. Infinity will provide a message to access the www.AlmirallMedPartD.com website to attest and confirm the Terms and Conditions discussion with the eligible patient. For questions, call 888-927-3499.
It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the Klisyri® cash-pay offer. Void if reproduced. Void where prohibited by law, taxed, or restricted. Program managed by InfinityRx.