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ILUMYA®
COPAY PROGRAM


WELCOME

With the ILUMYA® Copay Program, eligible patients with commercial insurance may
pay as little as $0* for ILUMYA®. If you do not qualify for the copay card,
there may still be savings options available to you—like the Early Access
Program.

With the ILUMYA® Copay Program, eligible patients with commercial insurance may
pay as little as $0* for ILUMYA®. If your patient does not qualify for the copay
card, there may still be savings options available to them—like the Early Access
Program.

*Required fields.

*Please select enrollment type.

SELECT ONE
 * Patient
 * Specialty Pharmacy

Must select enrollment type to continue
NEXT
Patient
I am 18 years of age or older and a permanent resident of the United States or a
United States territory. My patient is 18 years of age or older and is a
permanent resident of the United States or a United States territory.
Yes
No
You must be 18 years of age or older to participate in the ILUMYA® Copay
Program.
The patient must be 18 years of age or older to participate in the ILUMYA® Copay
Program.
I have commercial (also known as private) insurance coverage. This includes
insurance from an employer or from a health insurance marketplace. Does the
patient have commercial (also known as private) insurance coverage? This
includes insurance from an employer or from a health insurance marketplace.
Yes
No
We’re sorry; your response indicates that you are not eligible for the ILUMYA®
Copay Program. Please call the ILUMYA® Copay Program at 1-866-253-6677 to see if
other financial support options may apply.
We’re sorry; your response indicates that your patient is not eligible for the
ILUMYA® Copay Program. Please call the ILUMYA® Copay Program at 1-866-253-6677
to see if other financial support options may apply.
I am using a federal or state-funded health insurance program to pay for my
treatment of ILUMYA®. This includes, but is not limited to, Medicare, Medicaid,
Medigap, Veteran’s Affairs (VA), Department of Defense (DoD), TRICARE,
Government Health Insurance Plan available in Puerto Rico (formerly known as “La
Reforma de Salud”), or any other federal or state government program. Is the
patient using a federal or state-funded health insurance program to pay for
their treatment of ILUMYA®? This includes, but is not limited to, Medicare,
Medicaid, Medigap, Veteran’s Affairs (VA), Department of Defense (DoD), TRICARE,
Government Health Insurance Plan available in Puerto Rico (formerly known as “La
Reforma de Salud”), or any other federal or state government program.
Yes
No
We’re sorry; your response indicates that you are not eligible for the ILUMYA®
Copay Program. Please call the ILUMYA® Copay Program at 1-866-253-6677 to see if
other financial support options may apply.
We’re sorry; your response indicates that your patient is not eligible for the
ILUMYA® Copay Program. Please call the ILUMYA® Copay Program at 1-866-253-6677
to see if other financial support options may apply.
I am currently receiving the product for free through the ILUMYA® Patient
Assistance Program. Is the patient currently receiving the product for free
through the ILUMYA® Patient Assistance Program?
Yes
No
We’re sorry; your response indicates that you are not eligible for the ILUMYA®
Copay Program.
We’re sorry; your response indicates that your patient is not eligible for the
ILUMYA® Copay Program.
I acknowledge and agree that any of the information disclosed during enrollment,
including any patient information, contact information, demographic information,
and information related to my medical condition, treatments, and health
insurance and benefits, will be shared with Sun Pharmaceuticals, Inc., its
affiliates, service providers and other vendors (collectively "Sun
Pharmaceutical Industries Limited"). In addition, information shared by the
pharmacy/physician, such as the date the prescription was filled, the date the
medication was administered by the physician (if applicable) and the amount that
will be reimbursed by ILUMYA® will also be shared. I authorize Sun
Pharmaceutical Industries Limited, to receive, use, and share my personal
information in connection with the ILUMYA® Copay Program. I agree to be
contacted by phone, mail or email about the ILUMYA® Copay Program. For more
information, please see Sun Pharmaceutical Industries Limited’s Privacy Policy
at https://sunpharma.com/privacy-policy-new/. I acknowledge and agree on behalf
of myself and the patient that any of the information disclosed during
enrollment, including any patient information, contact information, demographic
information, and information related to the patient's medical condition,
treatments, and health insurance and benefits, will be shared with Sun
Pharmaceuticals, Inc., its affiliates, service providers and other vendors
(collectively "Sun Pharmaceutical Industries Limited"). In addition, information
shared by the pharmacy/physician, such as the date the prescription was filled,
the date the medication was administered by the physician (if applicable) and
the amount that will be reimbursed by ILUMYA® will also be shared. I authorize
Sun Pharmaceutical Industries Limited, on behalf of the patient, to receive,
use, and share the patient's personal information in connection with the ILUMYA®
Copay Program. I agree to be contacted by phone, mail or email about the ILUMYA®
Copay Program. For more information, please see Sun Pharmaceutical Industries
Limited's Privacy Policy at https://sunpharma.com/privacy-policy-new/.
Yes
No
You must agree to the above terms to participate in ILUMYA® Copay Program.
Your patient must agree to the above terms to participate in ILUMYA® Copay
Program.
I certify that I have accessed and reviewed the full Program Terms and
Conditions by visiting https://www.ilumya.com/savings. I certify that I have
accessed and reviewed the full Program Terms and Conditions with the patient by
visiting https://www.ilumya.com/savings.
Yes
No
Please use the link to access and review the full Program Terms and Conditions
if you wish to participate in ILUMYA® Copay Program.
If your patient would like to participate in ILUMYA® Copay Program, please use
the link to access and review the full Program Terms and Conditions to continue
the enrollment.
NEXT
Please enter your First Name.
Please enter Patient’s First Name.

Please enter your Last Name.
Please enter Patient’s Last Name.

*Date of Birth Month January February March April May June July August September
October November December Day
01020304050607080910111213141516171819202122232425262728293031 Year
2006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904
Please enter your Date of Birth.
Please enter Patient’s Date of Birth.
*Gender Male Female Other
Please select Gender.
Please select Gender.
Please enter your Address.
Please enter Patient’s Address.

Please enter your City.
Please enter City.
*State
ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY
Please enter your State.
Please enter State.
Please enter ZIP Code.
Please enter ZIP Code.
Please enter your Phone Number.
Please enter Patient’s Phone Number.
Please enter valid Email.
Please enter valid Email.
SUBMIT



Copay PROGRAM: Patients with commercial health insurance who qualify to
participate may pay as little as $0 per dose for an ILUMYA® prescription. To
participate in the ILUMYA® Copay Program (“Program”): the patient must have
commercial health insurance that provides coverage for ILUMYA® and be a resident
of the United States, Puerto Rico, Guam, or the Virgin Islands.

This Program is offered to, and intended for the sole benefit of, eligible
patients, and may not be utilized for the benefit of third parties, including,
without limitation, third party payers, pharmacy benefit managers, or the agents
of either.

This offer is limited to patient’s out-of-pocket cost for ILUMYA®, and is not
valid for any other out-of-pocket costs, including medical administration costs.
Out-of-pocket costs may include Copay, co-insurance, or deductible.

Patients and Prescribers must agree to not to seek any reimbursement for all or
any part of the Copay assistance received through the Program. By participating
in the Program, Patients and Prescribers are certifying that they understand the
Eligibility Rules and Terms and Conditions, that they have responded truthfully
to questions when enrolling in the program, activating the card, and that they
will disclose and report receipt of any Program benefits to the insurer, health
plan, or any third party that pays or provides reimbursement for the cost of
medications, if required.

This Program is not insurance. The Program is void where prohibited by law,
taxed, or restricted. Any benefit provided is not transferable and cannot be
combined with any other program, free trial, discount, prescription savings
card, or other offer. No purchase, other than for an ILUMYA® prescription, is
required to participate.

Personal data that you provide to the Program may be collected, analyzed, and
shared with the program sponsor for market research and other lawful purposes,
but only in aggregated and de-identified form.

This offer may be rescinded, revoked, or cancelled at any time, without further
notice, and the rules may be amended at any time, without further notice.

The following patients are ineligible for this program:

 * Patient’s age and diagnosis are not FDA-approved
 * Patients enrolled in any state or federally-funded insurance program,
   including, but not limited to, Medicare, Medicaid, TRICARE, Veterans Affairs
   Health Care, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or
   any other state or federal assistance program
 * Patients who are members of health plans that claim to eliminate their
   out-of-pocket costs (“accumulator adjustment” or “copay maximizer” programs)
   are not eligible for cost support, and as noted above, may have support
   reduced to $6,000 per calendar year.
 * Patients with no insurance or cash-paying patients

Call ILUMYA® Copay Program 1-866-253-6677 Monday - Friday 8:00 am - 8:00 pm ET

Indication and Important Safety Information and full Terms and Conditions for
participating in ILUMYA SUPPORT® Patient Services Programs at www.Ilumya.com or
www.Ilumyapro.com. ILUMYA and ILUMYA SUPPORT are registered trademarks of Sun
Pharmaceutical Industries Limited.
All other trademarks are the property of their respective owners.

©2023 Sun Pharmaceutical Industries, Inc. All rights reserved.
PM-US-ILY-2373  08/2023

 * Terms of Use
 * Privacy Policy


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Patient already enrolled, please use Member ID below.

Member ID:    Start Date: .

Please contact ILUMYA® Copay Program at 866-253-6677
with any questions.


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