Teva’s ALVAIZ (eltrombopag tablets) Savings Program
At a potentially lower cost than current eltrombopag treatments,
Pay as little as $0* for Teva’s ALVAIZ
*Offer covers commercially insured patients only. Please note, this offer is not available for patients eligible for Medicare, Medicaid, or any other form of government insurance. Out-of-pocket costs may vary based on insurance coverage. Limitations apply. See full Terms and Conditions for eligibility restrictions.
Savings Program Terms and Conditions
Terms, Conditions, and Eligibility Requirements: Eligible patients must have commercial prescription insurance with coverage for Teva’s ALVAIZ™ (eltrombopag tablets). Uninsured and cash-paying patients are NOT eligible for this Program. Patients enrolled in any state or federally funded healthcare program, including but not limited to, Medicare, Medigap, Medicaid, VA, DOD, TRICARE, Puerto Rico Government Health Insurance Plan, Medicare-eligible patients enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees, are NOT eligible for this Program. Cash Discount Cards and other noninsurance plans are not valid as primary under this Program. This Program is restricted to residents of the United States and United States territories.
Patients may pay as little as $0 out of pocket for Teva’s ALVAIZ. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. Patient is responsible for costs above maximum benefit amounts. This Program is not insurance. Void if copied, transferred, purchased, altered, or traded and where prohibited and restricted by law. The Program is not transferable. No substitutions are permitted. The Program form may not be sold, purchased, traded, or counterfeited. Void if reproduced. The Program benefit cannot be combined with any other financial assistance program, free trial, discount, prescription savings card, or other offer. This Program is managed by Mercalis on behalf of Teva Pharmaceuticals USA, Inc. Teva Pharmaceuticals USA, Inc. and its affiliates reserves the right to make eligibility determinations, to set Program benefit maximums, to monitor participation, and to change, rescind, revoke, or discontinue this Program at any time without notice. Limit one Program enrollment per individual. If you have any questions regarding this Program, your eligibility or benefits, or if you wish to discontinue your participation, please call 844-248-7949. Expiration Date: 12/31/2024.
Valid only for Teva’s ALVAIZ, National Drug Codes: 00480-3273-56, 00480-3274-56, 00480-3275-56, and 00480-3276-56
To the Patient: By redeeming this Program, you acknowledge that you are an Eligible Patient and you understand and agree to comply with the terms and conditions of this Program.
This Program is for eligible Commercially Insured Patients only. Patients may pay as little as $0 out of pocket for Teva’s ALVAIZ. Maximum Program assistance per prescription and annual benefits apply and out-of-pocket expenses may vary. This Program must be presented along with your prescription for Teva’s ALVAIZ and your primary insurance card to participate in this Program. Program not valid for Non-Insured/Cash-Paying Patients or where Teva’s ALVAIZ is not covered by the primary insurance.
To the Pharmacist: When you apply this Program, you are certifying that Teva’s ALVAIZ is being dispensed to an Eligible Patient in compliance with these terms and conditions and the Pharmacy has not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription. For Commercially Insured Patients, please submit this claim to the primary Third-Party Payer first, then submit the balance due to Mercalis as a Secondary Payer COB (coordination of benefits) with patient responsibility and a valid Other Coverage Code (e.g., 08).
Reimbursement will be received from Mercalis. For questions regarding processing, please call the Help Desk at 844-248-7949.
IMPORTANT SAFETY INFORMATION
WARNINGS and PRECAUTIONS
Hepatic Decompensation in Patients with Chronic Hepatitis C. In patients with chronic hepatitis C, ALVAIZ in combination with interferon and ribavirin may increase the risk of hepatic decompensation.
Hepatotoxicity. ALVAIZ may increase the risk of severe and potentially life-threatening hepatotoxicity.
Increased Risk of Death and Progression of Myelodysplastic Syndromes to Acute Myeloid Leukemia. In a clinical trial of patients with intermediate to high risk MDS with thrombocytopenia, an increased number of progressions from MDS to AML was observed compared to placebo.
Thrombotic/Thromboembolic Complications may result from increases in platelet counts with ALVAIZ. Reported thrombotic/thromboembolic complications included both venous and arterial events and were observed at low and at normal platelet counts.
Cataracts. In clinical trials, development or worsening of cataracts was reported in patients treated with eltrombopag.
ADVERSE REACTIONS
The following clinically significant adverse reactions associated with ALVAIZ are described above.
- Hepatic Decompensation in Patients with Chronic Hepatitis C
- Hepatotoxicity
- Increased Risk of Death and Progression of Myelodysplastic Syndromes to Acute Myeloid Leukemia
- Thrombotic/Thromboembolic Complications
- Cataracts
Common adverse reactions associated with the use of ALVAIZ observed in placebo-controlled clinical trials in adults and pediatric patients include nausea, diarrhea, upper respiratory tract infection, nasopharyngitis, cough, anemia, pyrexia, and fatigue.
USE IN SPECIFIC POPULATIONS
Pregnancy and Lactation
There is insufficient data in pregnant women to assess any drug-associated risks for major birth defects, miscarriage, or adverse maternal or fetal outcomes. Due to the potential for serious adverse reactions in a breastfed child from eltrombopag, breastfeeding is not recommended during treatment.
Pediatric Use
The safety and effectiveness of ALVAIZ have been established in pediatric patients 6 years and older with persistent or chronic ITP. The safety and effectiveness of ALVAIZ have not been established in pediatric patients less than 6 years of age with persistent or chronic ITP. The safety and effectiveness in pediatric patients with thrombocytopenia associated with chronic hepatitis C and refractory severe aplastic anemia have not been established.
INDICATIONS AND USAGE
Treatment of Thrombocytopenia in Patients with Persistent or Chronic Immune Thrombocytopenia
ALVAIZ® (eltrombopag tablets) are indicated for the treatment of thrombocytopenia in adult and pediatric patients 6 years and older with persistent or chronic immune thrombocytopenia (ITP) who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. ALVAIZ should be used only in patients with ITP whose degree of thrombocytopenia and clinical condition increase the risk for bleeding.
Treatment of Thrombocytopenia in Patients with Hepatitis C Infection
ALVAIZ is indicated for the treatment of thrombocytopenia in adult patients with chronic hepatitis C to allow the initiation and maintenance of interferon-based therapy. ALVAIZ should be used only in patients with chronic hepatitis C whose degree of thrombocytopenia prevents the initiation of interferon-based therapy or limits the ability to maintain interferon-based therapy.
Treatment of Severe Aplastic Anemia
ALVAIZ is indicated for the treatment of adult patients with severe aplastic anemia who have had an insufficient response to immunosuppressive therapy.
Limitations of Use
- ALVAIZ is not indicated for the treatment of patients with myelodysplastic syndromes (MDS).
- Safety and efficacy have not been established in combination with direct-acting antiviral agents used without interferon for treatment of chronic hepatitis C infection.
Please see the full Prescribing Information, including Medication Guide and Boxed Warning.