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All eligible commercially insured patients pay $25 or less ...

Visit to download the enrollment form Pharmacist has questions? They can review savings offer details before prescription processing at:StoreNet> Rx> Patient Care and search for Kaleo Have your prescription sent to Walgreens for in-store pickupEnroll in home delivery to have AUVI-Q delivered to your doorstepAll eligible commercially insured patients pay $25 or less for AUVI-Q*OR*Terms and Conditions: Only valid for commercially insured patients in the 50 United States and DC through the direct delivery service and/or designated retail pharmacies. Limit two (2) cartons of AUVI-Q per dose, per patient each calendar year. Individual insurance plan requirements may affect the redemption of the offer. OUT-OF-POCKET COSTS MAY VARY. Not eligible if prescriptions are paid for in part/full by state or federally funded program(s), like Medicare Part D, Medicaid, Vet. Aff., Dept. of Def.

All eligible commercially insured patients pay $25 or less for AUVI-Q* OR *Terms and Conditions: Only valid for commercially insured patients in the 50 United States and DC through the direct delivery service and/or designated retail pharmacies. Limit two (2) cartons of AUVI-Q per dose, per patient each calendar year. Individual

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Transcription of All eligible commercially insured patients pay $25 or less ...

1 Visit to download the enrollment form Pharmacist has questions? They can review savings offer details before prescription processing at:StoreNet> Rx> Patient Care and search for Kaleo Have your prescription sent to Walgreens for in-store pickupEnroll in home delivery to have AUVI-Q delivered to your doorstepAll eligible commercially insured patients pay $25 or less for AUVI-Q*OR*Terms and Conditions: Only valid for commercially insured patients in the 50 United States and DC through the direct delivery service and/or designated retail pharmacies. Limit two (2) cartons of AUVI-Q per dose, per patient each calendar year. Individual insurance plan requirements may affect the redemption of the offer. OUT-OF-POCKET COSTS MAY VARY. Not eligible if prescriptions are paid for in part/full by state or federally funded program(s), like Medicare Part D, Medicaid, Vet. Aff., Dept. of Def.

2 , or Tricare, and where prohibited by law. OFFER IS NOT INSURANCE. Offer cannot be sold, purchased, traded, transferred, and cannot be combined with any other offer. Cash discount cards are not commercial payers and are not eligible to be used for this program. Offer provided by kal o, and it may change at any time without notice. Call 844-357-3968 for questions regarding offer and AUVI-q are registered trademarks of kaleo, Inc. 2021 kaleo, Inc. CM-US-AQ-2234If you ve been prescribed AUVI-Q, show this page to a pharmacy team memberEach carton comes with 2 auto-injectors and 1 trainer.

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Frequently Asked Questions Obtaining AUVI-Q …

Frequently Asked Questions Obtaining AUVI-Q …

www.auvi-q.com

Does Tricare cover AUVI-Q? We encourage you to discuss with your doctor and contact Tricare requesting coverage as AUVI-Q may be covered by Tricare with a patient co-pay.

  Question, Frequently, Asked, Obtaining, Auvis, Frequently asked questions obtaining auvi

kaléo Cares Patient Assistance Program Enrollment Form

kaléo Cares Patient Assistance Program Enrollment Form

www.auvi-q.com

kaléo Cares Patient Assistance Program Enrollment Form WEB DOWNLOAD Please fax completed forms from prescriber’s office to: (800) 943-1730 kaleo, Inc (kaléo), the maker of AUVI-Q, understands that some patients may have financial difficulties that prevent them from obtaining necessary medications.

  Programs, Patients, Care, Assistance, Cares patient assistance program

Ask your doctor if AUVI-Q is right for you. (844) 357-3968 ...

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www.auvi-q.com

Drug: AUVI-Q® (epinephrine injection, USP) £ 0.1 mg £ 0.15 mg £ 0.3 mg Dispense as Written: £ Yes ICD Diagnosis Code: £ Quantity: £ 1Carton(2 auto-injectorsand1trainer) £ 2Cartons(4 auto-injectorsand2trainers) £ Other: Refills: £ 1 £ 2 £ Other: Locations for EAI: £ Home £ Work £ School £ Other:

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CM-US-AQ-1636 kaléo Cares Patient Assistance Program ...

CM-US-AQ-1636 kaléo Cares Patient Assistance Program ...

www.auvi-q.com

kaléo Cares Patient Assistance Program Enrollment Form Web Download Please fax completed forms from prescriber’s office to: (800) 943-1730 For assistance with any questions, call 502-213-7601 • Monday through Friday from 8am to 7pm Eastern Standard Time For additional information on AUVI-Q, please visit our website AUVI-Q.com ©2020 kaleo, Inc.

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