Program Details and Eligibility Requirements for Patients

• You may be eligible for this offer if: (1) You are a resident of Puerto Rico or the United States who is 18 years of age or older and are insured by commercial insurance that does not cover the full cost of your prescription (you have a co-pay obligation); and (2) Your prescriptions are not covered in full or in part by any state or federally funded insurance program, including but not limited to Medicare, Medicaid, Medigap, Veterans Affairs (VA) or Department of Defense (DOD). Patients who move from commercial to state or federally funded prescription insurance will no longer be eligible for this offer.
• Eligible patients with a co-pay (out-of-pocket expense) for a 30-day supply of Onglyza^® (saxagliptin) tablets of more than $10 who present an activated card together with a valid prescription for Onglyza tablets at the time of purchase may be able to receive up to $100 in savings per month. Savings not applicable to monthly out-of-pocket expenses of $10 or less.
• The first activation of the card will be valid for 24 months. Every 12 months thereafter, patients will be required to renew eligibility in order to continue participating in the offer.
• Your acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value received as may be required by your insurance provider.
• Patients, pharmacists, and prescribers cannot seek reimbursement, from health insurance or any third party, for any part of the benefit received by the patient through this offer.
• Card activation and use must take place by 12/31/2013. In accordance with Massachusetts law, program expiration date in MA is July 1, 2015.
• Only valid in the United States and Puerto Rico; this offer is void where restricted or prohibited by law.
• This offer is non-transferable, no substitutions are permissible, and offer cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription.
• Card may not be sold, purchased, traded, or counterfeited. Reproductions of this card are void.
• Bristol-Myers Squibb and AstraZeneca reserve the right to discontinue or change this offer at any time without notice.
• This offer is not conditioned on any past, present or future purchase, including refills.
• No membership fees. Card is not an insurance card.
• By using this card, you and your pharmacist understand and agree to comply with these Program Details and Eligibility Requirements.

Patient Rebate Process When Using a Mail Order Pharmacy
(or if Your Retail Pharmacy Does Not Accept the Value Card):

Follow these simple steps after activating your card:

1. Call your mail order pharmacy to check if they accept value cards. If they do, provide them your value card i.d. number after they receive your prescription. You will receive the rebate when the pharmacy processes your prescription payment.
2. If they do not accept value cards:
   1. Call the phone number on your card, 1-866-747-4958 to request a patient rebate form, or go to http://www.patientrebateonline.com to download a form.
   2. When you receive your form complete and sign it. Then attach the original mail order receipt and return to the address listed on the form.
   3. Remember to keep a copy of your receipts for your records. You should receive your rebate check in about 3–4 weeks.
3. Remember, you will need to request/download a form each time you get a refill of your prescription, and complete steps 2a. & 2b. to get your rebate.

Please click here for Medication Guide, and click here for US Full Prescribing Information for ONGLYZA (saxagliptin).