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  • ELIGIBILITY
  • PATIENT INFORMATION

Eligibility for Your Patients

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Required Field
Is the patient a United States Resident?
Does the patient currently have commercial insurance for a portion of the prescription drug cost?
Is the patient enrolled in any federal or state subsidized healthcare program that covers a portion of your prescription drug costs, including Medicare (such as Medicare Part D prescription drug benefit), Medicaid, TRICARE, or any other federal or state healthcare plan, including pharmaceutical assistance programs?

* By activating the co-pay card, your patient agrees to the following statements:

  • Your patient’s information above is true and correct
  • Your patient is not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare or Medicaid, or any private indemnity or HMO insurance that reimburses your patient the entire cost of your prescription drug
  • You agree that your patient is not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees
  • Should your patient begin receiving prescription benefits from one of these types of programs at any time, your patient will no longer participate in this savings program.

Co-pay Savings Program for Mirena TERMS & CONDITIONS

  • Patient must meet the eligibility requirements of the Co-pay Savings Program for Mirena; for example, only commercially insured patients are eligible
  • Patient must inform the Co-pay Savings Program for Mirena of change in insurance status
  • It is required that the patient understand, accept, and meet the terms of all the Co-pay Savings Program for Mirena requirements
  • Use of the Co-pay Savings Program for Mirena must be consistent with and not prohibited by the requirements of the patient’s health insurance
  • The Co-pay Savings Program for Mirena benefit has a max of $1157, per patient
  • The Co-pay Savings Program for Mirena is for commercially insured patients using Mirena for an approved FDA indication
  • The Co-pay Savings Program for Mirena does not cover costs for charges associated with patient visits
  • Offer valid only for patients treated in the USA, including Puerto Rico, Guam and US Territories
  • Bayer reserves the right to determine eligibility, monitor participation, equitably distribute product and modify or discontinue the Co-pay Savings Program for Mirena at any time with or without notice
  • Patient agrees to provide necessary health information to the administrators of the Co-pay Savings Program for Mirena 

For questions about the Co-pay Savings Program for Mirena, please call us at 1-833-244-2719.

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Eligible patients may pay as little as $20 and save up to $1157. Patients who are enrolled in any type of government insurance or reimbursement programs are not eligible. As a condition precedent of the co-payment support provided under this program, e.g., co-pay refunds, participating patients and pharmacies are obligated to inform insurance companies and third-party payers of any benefits they receive and the value of this program, and may not participate if this program is prohibited by or conflicts with their private insurance policy, as required by contract or otherwise. Void where prohibited by law, taxed, or restricted. Patients enrolled in the Bayer US Patient Assistance Foundation are not eligible. Bayer may determine eligibility, monitor participation, equitably distribute product and modify or discontinue any aspect of the Co-pay Savings Program for Mirena at any time, including but not limited to this commercial co-pay assistance program.

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Site Last Modified 01/2024. PP-MIR-US-0442-1PP-MIR-US-0412-1. July 2022.