Through the UCERIS Instant Savings Program, eligible patients with commercial insurance may pay no more than $25 co-pay for each UCERIS prescription (maximum benefits apply).† * = required Enroll now in the UCERIS Instant Savings Program *Card ID: *First name: *Last name: *Address 1: Address 2: *City: *State: Loading...*Zip: *Email: *Confirm email: *Phone number: *DOB: * Is the patient who will be using this savings card 18 years of age or older and a resident of the United States? * Is the patient who will be using this savings card an eligible commercially-insured patient? * Is the patient who will use this savings card eligible for reimbursement of prescriptions (in whole or in part) under any federal, state or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare programs? Are you also interested in receiving additional communications (health tips, wellness tools, coupons, other discounts, educational materials, product information, etc) from Salix Pharmaceuticals? Submit Eligibility Criteria and Terms and Conditions This offer is only valid for patients 18 years of age or older with commercial insurance, including commercially insured patients without coverage for UCERIS. Patients without commercial insurance are not eligible Eligible insured patients with coverage for UCERIS must pay the first $25 of their co-pay, and eligible insured patients without coverage for UCERIS must pay the first $25 of out-of-pocket expense and then Salix Pharmaceuticals will pay the remaining co-pay/out-of-pocket expense up to the maximum amount of $800 per fill Maximum benefits are as follows: UCERIS tablets: $800/prescription, for 1 use per month for a calendar year; UCERIS rectal foam: $800/prescription, for up to 8 uses in a calendar year. Patient is responsible for all additional costs and expenses after the maximum limit is reached This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, or the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs This offer is only good in the USA at participating retail pharmacies, and cannot be redeemed at other locations, including government-subsidized clinics or facilities This offer is not valid where otherwise prohibited, taxed, or otherwise restricted Patient is responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the co-pay card, as may be required This offer cannot be combined with other offers This card has no cash value and no other purchase is necessary This offer is nontransferable and no substitutions are permitted This card is not health insurance You understand and agree to comply with the terms and conditions of this offer as set forth above. Offer expires December 31, 2018 Salix Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice The UCERIS Instant Savings Card Savings card must be activated prior to use by visiting www.uceris.com or by calling 855-558-1669 Participating patients must present their activated UCERIS Instant Savings Card for every eligible prescription fill or refill Mail Order The UCERIS Instant Savings Card may be used for mail-order prescriptions Reimbursement: Benefits that could not be processed through mail order may qualify for reimbursement. Please visit www.patientrebateonline.com for instructions on how to mail in your prescription receipt for reimbursement †Restrictions apply. Please see "Eligibility Criteria and Terms and Conditions" above.