Welcome 8146

State Epinephrine Auto-Injector Program

My pharmacy is located in Colorado.

Colorado

Pursuant to Colorado law, to be eligible for this program and receive a 2-pack EPIPEN, EPIPEN JR, Epinephrine Injection, USP Auto-Injector 0.3 mg (the authorized generic to EPIPEN), or Epinephrine Injection, USP Auto-Injector 0.15 mg (the authorized generic to EPIPEN JR) (each, an "Epinephrine Auto- Injector") for no more than $60 for each 2-pack of Epinephrine Auto-Injectors, the patient must:

Be a resident of Colorado
Have a valid prescription for Epinephrine Auto-Injector
Be uninsured or have commercial insurance that does not limit the patient's cost sharing to no more than $60 for a 2-pack of Epinephrine Auto-Injectors
Not be eligible for or enrolled in a state or federally funded healthcare program, such as Health First Colorado or Medicare
Present identification proving Colorado residency including, but not limited to, a valid Colorado identification card or driver's license, a printed bill (utility, telephone, internet, cable, insurance, mortgage, rent, waste disposal, water or sewer, medical or other bill), a credit card or bank statement, a pay stub or earnings statement, a post-marked change of address confirmation, a printed rent receipt or residential lease, a transcript or report card from an accredited school, a vehicle title or registration, an insurance policy, a government issued letter or state or federal government issued check, or a record of medical service. If the patient is a minor under the age of 18, the patient's parent or legal guardian must provide proof of residency.

Colorado Epinephrine Auto-Injector Affordability Program application (to be completed by patient)

By providing your patient's information to sign up your patient for the Colorado Epinephrine Auto-Injector Savings Card program, you are certifying that you have received from your patient all permissions required under law (including authorizations under HIPAA and state law) to disclose this information to Mylan Specialty L.P., a Viatris Company, and you have notified the patient of the Savings Card full terms and conditions.

^* Does your patient have:

Commercial Insurance

Government Employment or Funded Insurance (like Medicare or Medicaid)

No Insurance

You are not eligible to participate in this program.

^* Patient First Name

^* Patient Last Name

^* Patient Address

^* Patient City

^* Patient State

^* Patient Zip Code

^* Patient Date of Birth

Your provider information may be disclosed to governmental entities as required by law. Please review the full Viatris Privacy Statement for further information.

I certify, by checking and submitting this page I have received a completed state application from the patient and will dispense a Viatris Epinephrine Auto-Injector product to the eligible patient in accordance with the Colorado Epinephrine Auto-Injector Affordability Program. In addition, I certify that I will comply with the requirements of the Colorado Epinephrine Auto-Injector Affordability Program, including, without limitation, that I will not seek any reimbursement from any third-party payer for the Viatris Epinephrine Auto-Injector product, except for the manufacturer savings card program available under the Viatris State Epinephrine Auto-Injector Program.*

*Required

Colorado Epinephrine Auto-Injector Program Savings Card Terms and Conditions

With this Savings Card, you may pay up to $60 for each EPIPEN 2-PAK^®, EPIPEN JR 2-PAK^®, Epinephrine Injection, USP Auto-Injector 0.3 mg (the authorized generic to EPIPEN^® (epinephrine injection, USP) Auto-Injector), or Epinephrine Injection, USP Auto-Injector 0.15 mg (the authorized generic to EPIPEN JR^® (epinephrine injection, USP) Auto-Injector) (each, an "Epinephrine Auto-Injector") carton [two (2) auto-injectors] per prescription fill, while this program remains in effect. Savings may vary depending upon your out-of-pocket costs. If eligible, this offer may be used for up to a 12-month period. This offer may be used for up to a total of six (6) Epinephrine Auto-Injector cartons per 12-month period. No other purchase is necessary. Valid prescription with Prescriber ID# is required. Mylan Specialty L.P., a Viatris Company, reserves the right to amend or end this program at any time without notice.

Eligibility Requirements: This Savings Card is only valid in the state of Colorado for claims submitted for eligible Colorado residents pursuant to the Colorado Epinephrine Auto-Injector Affordability Program. This Savings Card is not valid for insured patients who pay $60 or less for each Epinephrine Auto-Injector carton. Patients must be uninsured or have commercial insurance that does not limit the patient's cost sharing to no more than $60 for an Epinephrine Auto-Injector carton. This program is not valid patients who are covered by any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TRICARE (regardless of whether the applicable Epinephrine Auto-Injector is covered by such government program); not valid if the patient is Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; and not valid if the patient's insurance plan is paying the entire cost of this prescription. This Savings Card can be redeemed only by patients or patient guardians who are 18 years of age or older. This program is void outside Colorado or where prohibited by law, taxed, or restricted.

This Savings Card is not health insurance. This Savings Card is not transferable, and the amount of the savings cannot exceed the patient's out-of-pocket costs. This Savings Card cannot be combined with any other rebate/coupon, cash discount card, free trial, or similar offer for the specified prescription. This Savings Card is not redeemable for cash.

NOTICE: Data related to your use of this Savings Card may be collected, analyzed and shared with Mylan Specialty L.P., a Viatris Company, for market research and other purposes related to assessing its savings card programs. Data shared with Mylan Specialty L.P., a Viatris Company, will be aggregated and de-identified, meaning it will be combined with data related to other savings card redemptions and will not identify you.

Patient Instructions: By using this Savings Card, you hereby accept and agree to abide by these terms and conditions. Further, you acknowledge and agree that you currently meet the eligibility criteria and other requirements described herein every time you use this Savings Card and that you understand and will comply with the following additional terms and conditions:

You have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription, and you will not apply any out-of-pocket costs incurred using this Savings Card toward any government insurance benefit out-of-pocket cost obligations, such as Medicare Part D True Out-of-Pocket (TrOOP) costs.

You agree to report the use of this Savings Card to your commercial insurer if required.

A Savings Card, a prescription drug insurance card (where applicable), and a valid prescription for the applicable Epinephrine Auto-Injector, must be presented to your pharmacist.

Should you begin receiving prescription benefits from any government funded program, you will withdraw from this Savings Card program.

Pharmacist Instructions: When you accept this Savings Card, you are certifying that you have received this Savings Card from an eligible patient; you have received a valid prescription for the applicable Epinephrine Auto-Injector for an eligible patient; you have dispensed the product as indicated; you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription; and you will otherwise comply with these terms and all applicable terms and conditions. You further certify that your participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that you have as a pharmacy provider, and that you will report the use of this Savings Card to the patient's insurer if required.

Submit transaction to McKesson Corporation using BIN #610524.
For commercially insured patients, input this Savings Card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable patient savings will be displayed in the transaction response. Other cash discount cards are not valid as primary insurance under this offer.
Acceptance of this Savings Card and your submission of claims for the Colorado Epinephrine Auto-Injector Program Savings Card program are subject to the Savings Card Terms and Conditions posted at www.activatethecard.com/8146
Acceptance of this Savings Card and your submission of claims for the Colorado Epinephrine Auto-Injector Program Savings Card program are subject to the LoyaltyScript^® program Terms and Conditions posted at www.mckesson.com/mprstnc.
For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript^® for the Colorado Epinephrine Auto-Injector Program Savings Card program at 800-657-7613 (8:00 AM-8:00 PM EST, Monday-Friday).