Sign up to receive your STAVZOR Easy Save Pharmacy Card

Save $50 off your co-pay for EVERY prescription

Dear Patient:
The STAVZOR Easy Save Pharmacy Card will pay for up to $50 for EVERY STAVZOR prescription. If you have insurance, the STAVZOR Easy Save Pharmacy Card will likely prevent you from having to pay any money out-of-pocket for your STAVZOR. It will likely be FREE! To participate in the program, fill out the form below to receive your very own STAVZOR Easy Save Pharmacy Card, then go to your pharmacy and present your STAVZOR Easy Save Pharmacy Card along with your STAVZOR prescription. It's that easy!

When you leave the pharmacy with your STAVZOR medication, be sure to take your STAVZOR Easy Save Pharmacy Card with you. Do NOT leave it with the pharmacist. Remember, your card will save you $50 off EVERY prescription so you want to be sure not to leave your STAVZOR Easy Save Pharmacy Card behind.

How to save money with your STAVZOR Easy Save Pharmacy Card

Present your STAVZOR Easy Save Pharmacy Card when paying for your STAVZOR prescription. That's it! It's that easy to save up to $50 on EVERY prescription
Never leave your STAVZOR Easy Save Pharmacy Card at the pharmacy. You'll want to bring it to the pharmacy each time you fill a STAVZOR prescription.

Read the Eligibility Criteria below to see if you qualify. If you do, simply fill out the required information on this form and click "submit." Your STAZVOR Easy Save Pharmacy Card will arrive in approximately 2 weeks.

Note: Lines with an asterisk (*) must be filled in.

*First Name:
*Last Name:
*Street Address:
Apt. Number:
*City:
*State:
*Zip:
Phone:
*Email Address:
Birthdate:

Gender:
Male
Female

How did you hear about our website:

Which of the following best describes your familiarity with STAVZOR?
Have never heard of STAVZOR prior to today
Have heard of STAVZOR, but have not yet discussed with my doctor
Have received a prescription for STAVZOR, but have not yet filled it
Have filled a prescription for STAVZOR, but have not yet gotten a refill
Have filled a prescription for STAVZOR 2 or more times

Please read the information below before you submit your request.
Concerning Confidentiality: Noven Therapeutics respects your right to have personal and medical information kept confidential. When you click the "Submit" button below, you indicate to us that you want us to use the information you have provided for the purpose of administering the rebate [and sending you an introductory mailing about STAVZOR]. Noven Therapeutics, and companies working with Noven Therapeutics, will not share your personal and medical information with any third parties (such as outside mailing lists).

	Check here if you also agree that Noven Therapeutics and companies working with Noven Therapeutics may use your information to help develop new Noven Therapeutics products, services and programs, provide you in the future with materials you may find useful, and contact you about health-related topics.
	Check here if you also agree that Noven Therapeutics may contact you from time to time about special offers and updates on STAVZOR and related health issues.

Eligibility Criteria:

This offer is not valid for prescriptions reimbursed in whole or in part by Medicaid, Medicare, federal or state programs (including any state prescription drug programs).
The card is good for use only with STAVZOR prescriptions at the time the prescription is filled by the pharmacist and dispensed to the patient. Patient must present a valid health plan prescription benefit card along with this card at time of purchase.
Offer is not valid on prescriptions dispensed prior to the date of the first use of this card.
Offer good only in the USA at participating retail pharmacies and cannot be redeemed at government-subsidized clinics.
This offer is not valid for residents of Massachusetts whose prescriptions are covered in whole or in part by third party insurance, or where otherwise prohibited by law.
This offer is good for up to a maximum of $50 in savings on any one STAVZOR prescription.
Please allow 10 to 14 business days for delivery.
Noven Therapeutics has the right to cancel this offer, or change it, without notice.

If you have questions about the STAVZOR Co-Pay Benefit Program, please call 800-773-0116.