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Submission: On November 16 via manual — Scanned from DE
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CLL/SLL
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
MCL
Previously Treated Mantle Cell Lymphoma
WM
Waldenstrom's Macroglobulinemia
MZL
Previously Treated Marginal Zone Lymphoma
CGVHD
Previously Treated Chronic Graft Versus Host Disease
* Choose Indication
* Affording IMBRUVICA®
* Taking IMBRUVICA®
* Patient Support & Savings
* Important Side Effect Information
* Prescribing Information
* Healthcare Professionals
Change Condition
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Previously Treated
Mantle Cell Lymphoma Waldenstrom's Macroglobulinemia Previously Treated Marginal
Zone Lymphoma Previously Treated Chronic Graft Versus Host Disease
RETRIEVE YOUR MEMBER ID
Complete the information below and receive a confirmation page immediately with
your copay card information. If you would like a duplicate record of your card,
enter your email address.
Required*
Phone number*
Date of birth (MM/DD/YYYY)*
Zip code*
Email address
Submit
SUCCESS! YOU CAN BEGIN TO USE THE IMBRUVICA® COPAY CARD IMMEDIATELY
Download your copay card information and present it along with a signed
prescription for IMBRUVICA® to your pharmacist for an instant savings that can
be applied toward out-of-pocket expenses on your prescription for IMBRUVICA®.
COPAY PROGRAM
RxBIN: 610524 RxGRP: IMB57962 RxPCN: Loyalty ISSUER: 80840 ID: XXXXXXXXXX
Eligible patients may pay as little as $10 per prescription of IMBRUVICA® until
the maximum limit of $24,600 per calendar year is reached. The IMBRUVICA® Copay
Card is available to patients with commercial prescription coverage for
IMBRUVICA® who meet eligibility criteria. The IMBRUVICA® Copay Card cannot be
used by patients receiving prescription reimbursement under any federal, state,
or government-funded insurance programs, including Medicare Part D, Medicare
Advantage Plan, Medicaid, Medigap, VA, DOD, and TRICARE, or where prohibited by
law or the patient’s health insurance provider.
Download Copay Card
To the Patient: You must present this card to the pharmacist along with your
prescription to participate in this program. If you have any questions regarding
your eligibility or benefits, or if you wish to discontinue your participation,
call the IMBRUVICA® By Your Side patient support program at 1-888-YourSide
(1-888-968-7743), (Monday - Friday, 8:00 AM - 8:00 PM ET). When you use this
card, you are certifying that you understand the program rules, regulations, and
terms and conditions. You are not eligible if prescriptions are paid by any
state or other federally funded programs, including, but not limited to Medicare
Part D, Medicare Advantage Plan, or Medicaid, Medigap, VA or DOD or TRICARE, or
where prohibited by law; and you will otherwise comply with the terms above.
To the Pharmacist: When you use this card, you are certifying that you have not
submitted and will not submit a claim for reimbursement under any federal, state
or other governmental programs for this prescription.
* Submit transaction to RxC Acquisition Company d/b/a RxCrossroads by McKesson
using BIN #610524
* If primary commercial prescription insurance exists, input card information
as secondary coverage and transmit using the COB segment of the NCPDP
transaction. Applicable discounts will be displayed in the transaction
response
* Acceptance of this card and your submission of claims for the IMBRUVICA®
Copay Program are subject to the LoyaltyScript® program Terms and Conditions
posted at www.mckesson.com/mprstnc
* The IMBRUVICA® Copay Card cannot be used by patients receiving prescription
reimbursement under any federal, state, or government-funded insurance
programs, including Medicare Part D, Medicare Advantage Plan, Medicaid,
Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient’s
health insurance provider
* The LoyaltyScript® card is not valid for use with any other prescription drug
discount or cash cards for IMBRUVICA®. Claims submitted utilizing the program
are subject to audit or validation
* For questions regarding setup, claim transmission, patient eligibility or
other issues, call the LoyaltyScript® for IMBRUVICA® program at
1-855-332-6211 (Monday - Friday, 8:00 AM - 8:00 PM ET, excluding holidays)
Pharmacyclics LLC, an AbbVie Company, reserves the right to rescind, revoke or
amend this offer at any time.
RxBIN: 610524 RxGRP: IMB57962 RxPCN: Loyalty ISSUER: 80840 ID: XXXXXXXXXX
To the Patient: You must present this card to the pharmacist along with your
prescription to participate in this program. If you have any questions regarding
your eligibility or benefits, or if you wish to discontinue your participation,
call the IMBRUVICA® By Your Side patient support program at 1-888-YourSide
(1-888-968-7743), (Monday - Friday, 8:00 AM - 8:00 PM ET). When you use this
card, you are certifying that you understand the program rules, regulations, and
terms and conditions. You are not eligible if prescriptions are paid by any
state or other federally funded programs, including, but not limited to Medicare
Part D, Medicare Advantage Plan, or Medicaid, Medigap, VA or DOD or TRICARE, or
where prohibited by law; and you will otherwise comply with the terms above.
To the Pharmacist: When you use this card, you are certifying that you have not
submitted and will not submit a claim for reimbursement under any federal, state
or other governmental programs for this prescription.
* Submit transaction to RxC Acquisition Company d/b/a RxCrossroads by McKesson
using BIN #610524
* If primary commercial prescription insurance exists, input card information
as secondary coverage and transmit using the COB segment of the NCPDP
transaction. Applicable discounts will be displayed in the transaction
response
* Acceptance of this card and your submission of claims for the IMBRUVICA®
Copay Program are subject to the LoyaltyScript® program Terms and Conditions
posted at www.mckesson.com/mprstnc
* The IMBRUVICA® Copay Card cannot be used by patients receiving prescription
reimbursement under any federal, state, or government-funded insurance
programs, including Medicare Part D, Medicare Advantage Plan, Medicaid,
Medigap, VA, DOD, and TRICARE, or where prohibited by law or the patient’s
health insurance provider
* The LoyaltyScript® card is not valid for use with any other prescription drug
discount or cash cards for IMBRUVICA®. Claims submitted utilizing the program
are subject to audit or validation
* For questions regarding setup, claim transmission, patient eligibility or
other issues, call the LoyaltyScript® for IMBRUVICA® program at
1-855-332-6211 (Monday - Friday, 8:00 AM - 8:00 PM ET, excluding holidays)
Pharmacyclics LLC, an AbbVie Company, reserves the right to rescind, revoke or
amend this offer at any time.
IMPORTANT SIDE EFFECT INFORMATION
Before taking IMBRUVICA®, tell your healthcare provider about all of your
medical
conditions, including if you:
* have had recent surgery or plan to have surgery. Your healthcare provider may
stop IMBRUVICA® for any planned medical, surgical, or dental procedure.
* have bleeding problems
* have or had heart rhythm problems, smoke, or have a medical condition that
increases your risk of heart disease, such as high blood pressure, high
cholesterol, or diabetes
* have an infection
* have liver problems
* are pregnant or plan to become pregnant. IMBRUVICA® can harm your unborn
baby. If you are able to become pregnant, your healthcare provider will do a
pregnancy test before starting treatment with IMBRUVICA®. Tell your
healthcare provider if you are pregnant or think you may be pregnant during
treatment with IMBRUVICA®.
* Females who are able to become pregnant should use effective birth control
(contraception) during treatment with IMBRUVICA® and for 1 month after the
last dose.
* Males with female partners who are able to become pregnant should use
effective birth control, such as condoms, during treatment with IMBRUVICA®
and for 1 month after the last dose.
* are breastfeeding or plan to breastfeed. Do not breastfeed during treatment
with IMBRUVICA® and for 1 week after the last dose.
Tell your healthcare provider about all the medicines you take, including
prescription and over-the-counter medicines, vitamins, and herbal supplements.
Taking IMBRUVICA® with certain other medicines may affect how IMBRUVICA® works
and can cause side effects.
HOW SHOULD I TAKE IMBRUVICA®?
* Take IMBRUVICA® exactly as your healthcare provider tells you to take it.
* Take IMBRUVICA® 1 time a day.
* Swallow IMBRUVICA® capsules or tablets whole with a glass of water.
* Do not open, break or chew IMBRUVICA® capsules.
* Do not cut, crush or chew IMBRUVICA® tablets.
* Take IMBRUVICA® at about the same time each day.
* If you miss a dose of IMBRUVICA® take it as soon as you remember on the same
day. Take your next dose of IMBRUVICA® at your regular time on the next day.
Do not take extra doses of IMBRUVICA® to make up for a missed dose.
* If you take too much IMBRUVICA® call your healthcare provider or go to the
nearest hospital emergency room right away.
WHAT SHOULD I AVOID WHILE TAKING IMBRUVICA®?
* You should not drink grapefruit juice, eat grapefruit, or eat Seville oranges
(often used in marmalades) during treatment with IMBRUVICA®. These products
may increase the amount of IMBRUVICA® in your blood.
WHAT ARE THE POSSIBLE SIDE EFFECTS OF IMBRUVICA®?
IMBRUVICA® may cause serious side effects, including:
* Bleeding problems (hemorrhage) are common during treatment with IMBRUVICA®,
and can also be serious and may lead to death. Your risk of bleeding may
increase if you are also taking a blood thinner medicine. Tell your
healthcare provider if you have any signs of bleeding, including: blood in
your stools or black stools (looks like tar), pink or brown urine, unexpected
bleeding, or bleeding that is severe or that you cannot control, vomit blood
or vomit looks like coffee grounds, cough up blood or blood clots, increased
bruising, dizziness, weakness, confusion, change in your speech, or a
headache that lasts a long time or severe headache.
* Infections can happen during treatment with IMBRUVICA®. These infections can
be serious and may lead to death. Tell your healthcare provider right away if
you have fever, chills, weakness, confusion, or other signs or symptoms of an
infection during treatment with IMBRUVICA®.
* Decrease in blood cell counts. Decreased blood counts (white blood cells,
platelets, and red blood cells) are common with IMBRUVICA®, but can also be
severe. Your healthcare provider should do monthly blood tests to check your
blood counts.
* Heart problems. Serious heart rhythm problems (ventricular arrhythmias,
atrial fibrillation, and atrial flutter), heart failure, and death have
happened in people treated with IMBRUVICA®, especially in people who have an
increased risk for heart disease, have an infection, or who have had heart
rhythm problems in the past. Tell your healthcare provider if you get any
symptoms of heart problems, such as feeling as if your heart is beating fast
and irregular, lightheadedness, dizziness, shortness of breath, swelling of
the feet, ankles, or legs, chest discomfort, or you faint. If you develop
any of these symptoms, your healthcare provider may do a test to check your
heart (ECG) and may change your IMBRUVICA® dose.
* High blood pressure (hypertension). New or worsening high blood pressure has
happened in people treated with IMBRUVICA®. Your healthcare provider may
start you on blood pressure medicine or change current medicines to treat
your blood pressure.
* Second primary cancers. New cancers have happened during treatment with
IMBRUVICA®, including cancers of the skin or other organs.
* Tumor lysis syndrome (TLS). TLS is caused by the fast breakdown of cancer
cells. TLS can cause kidney failure and the need for dialysis treatment,
abnormal heart rhythm, seizure, and sometimes death. Your healthcare provider
may do blood tests to check you for TLS.
The most common side effects of IMBRUVICA® in adults with B-cell malignancies
(MCL, CLL/SLL, WM and MZL) include:
* diarrhea
* tiredness
* muscle and bone pain
* rash
* bruising
The most common side effects of IMBRUVICA® in adults with cGVHD include:
* tiredness
* bruising
* diarrhea
* mouth sores (stomatitis)
* muscle spasms
* nausea
* pneumonia
Diarrhea is a common side effect in people who take IMBRUVICA®. Drink plenty of
fluids during treatment with IMBRUVICA® to help reduce your risk of losing too
much fluid (dehydration) due to diarrhea. Tell your healthcare provider if you
have diarrhea that does not go away.
These are not all the possible side effects of IMBRUVICA®. Call your doctor for
medical advice about side effects. You may report side effects to FDA at
1-800-FDA-1088.
General information about the safe and effective use of IMBRUVICA®
Medicines are sometimes prescribed for purposes other than those listed in a
Patient Information leaflet. Do not use IMBRUVICA® for a condition for which it
was not prescribed. Do not give IMBRUVICA® to other people, even if they have
the same symptoms that you have. It may harm them. You can ask your pharmacist
or healthcare provider for information about IMBRUVICA® that is written for
health professionals.
Please see the full Important Product Information.
USES
WHAT IS IMBRUVICA® (IBRUTINIB)?
IMBRUVICA® (ibrutinib) is a prescription medicine used to treat adults with:
* Mantle cell lymphoma (MCL) who have received at least one prior treatment
* Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL)
* Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma (SLL) with 17p
deletion
* Waldenström’s macroglobulinemia (WM)
* Marginal zone lymphoma (MZL) who require a medicine by mouth or injection
(systemic therapy) and have received a certain type of prior treatment
* Chronic graft versus host disease (cGVHD) after failure of 1 or more lines of
systemic therapy
It is not known if IMBRUVICA® is safe and effective in children.
IMPORTANT SIDE EFFECT INFORMATION
USES
Your use of the information on this site is subject to the terms of the Legal
Notice and new Privacy Policy of Pharmacyclics LLC. This site is published by
Pharmacyclics LLC which has developed the content in conjunction with Janssen
Biotech, Inc. Any information that is collected on this site may be shared
between Pharmacyclics LLC and Janssen Biotech, Inc. This information is intended
for use by our customers, patients, and healthcare professionals in the United
States and Puerto Rico only. Pharmacyclics LLC recognizes that the Internet is a
global communication medium; however laws, regulatory requirements, and medical
practices vary from country to country.
IMBRUVICA® (ibrutinib) is covered by U.S. Patents, which are listed in FDA's
Orange Book (available
at https://www.accessdata.fda.gov/scripts/cder/ob/default.cfm).
© Pharmacyclics LLC 2021
© Janssen Biotech, Inc. 2021
05/21 PRC-08192
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Zone Lymphoma Previously Treated Chronic Graft Versus Host Disease
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