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• • I need a Balcoltra Savings Program Coupon.I have a Balcoltra Savings Program Coupon.
    • Rx ID Number
• First Name
• Last Name
• Date of Birth
• ZIP Code
• Phone Number
• Email
• Confirm Email

• Avion respects individual privacy and values the confidence of our customers. The information pertaining to you that we collect will be used in accordance with our Privacy Policy. By providing your email address, you agree and acknowledge that you would like to receive information from Avion related to Balcoltra and the Balcoltra Savings Program, including site updates, education, and other Balcoltra products and services. If you later wish to opt out from receiving this information, you may click on the included opt-out link in future communications.

  If you provided a mobile number, clicking “Submit” will subscribe you to receive requested text messages from Avion containing notifications and reminders regarding our products, which may contain marketing content, on the mobile device that is personally owned by you. You represent that you have the authority to agree to receive SMS messages on the mobile number that you provided to us, or from which you sent the SMS request to us. Message frequency will be up to 3 times per month. Standard message and data rates may apply. SMS messaging is not available in all areas. Not all mobile devices or handsets may be supported. Avion is not liable for delayed or undelivered messages. Avion respects individual privacy and values the confidence of our customers. The information pertaining to you that we collect will be used in accordance with our Privacy Policy. By providing your email address, you agree and acknowledge that you would like to receive information from Avion related to Balcoltra, including site updates, education, and other Avion products and services. If you later wish to opt out from receiving this information, you may click on the included opt-out link in future communications. For additional assistance, please contact us.

• I agree, and I certify that the information I have provided above is true and correct.

• Please Answer the Following Questions

• Do you live in the United States or Puerto Rico?YesNo
  • Select a stateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Do you have commercial prescription drug insurance?YesNo
  • Select your insurance company Insurance CompanyAetnaCaremark PCSEnvisionExpress ScriptsHighmarkMedco Health SolutionsPrimeOther

• By activating your Balcoltra Savings Program Coupon, you certify that you are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these types of programs at any time, you will no longer participate in this savings program.

• I agree to this certification and I accept the Terms, Conditions, and Eligibility Criteria available here, below, or on my coupon.

1. This offer is only good for self-pay patients and commercial-prescription-drug-insured patients and is good for use only with a Balcoltra prescription at the time the prescription is filled by the pharmacist and dispensed to the patient.
2. Depending on your insurance coverage, most eligible insured patients pay no more than $21 (with a maximum benefit amount of up to $170) for each prescription fill. Other eligible insured patients and self-pay patients, check with your pharmacist for your co-pay discount. Maximum reimbursement limits may apply; patient out-of-pocket expense may vary.
3. This offer is not valid for patients enrolled in Medicare, Medicaid, TRICARE, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this coupon if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. Qualified health plans purchased through a health insurance exchange or marketplace established by a state government or the federal government are not considered to be government programs and are eligible for this program.
4. Each coupon is valid for unlimited refills. This coupon is not transferable. Avion reserves the right to rescind, revoke, or amend this offer without notice.
5. Offer not valid in any states where prohibited by law, taxed, or restricted.
6. The selling, purchasing, trading, or counterfeiting of this coupon is prohibited by law.
7. By redeeming this coupon, you acknowledge that you understand and agree to comply with the terms and conditions of this offer.

For questions about the Balcoltra Savings Program, please call 1-877-838-3846.