DISCOVER POTENTIAL SAVINGS

Sign up for Copay Assistance from ORGOVYX

Get help with out-of-pocket costs. Fill out the form below to find out if you're eligible.

Please see Program Terms, Conditions, and Eligibility Criteria.

Eligibility required. Commercially insured patients only. This copay program is subject to a calendar year maximum savings of $10,000. After the calendar year maximum savings is reached, patient will be responsible for the remaining out-of-pocket costs for ORGOVYX. The Copay Program is not valid for patients participating in Medicare, Medicaid, or other government healthcare programs. No membership fees. This offer is not health insurance. Available only to patients who have been diagnosed with an FDA-approved indication for ORGOVYX. Terms and conditions apply. For full program terms, conditions, and eligibility criteria please see full terms and conditions.

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Do you have commercial prescription drug insurance?

(If you have Medicaid, Medicare, or other government-sponsored prescription insurance, such as VA/DOD, select “No”)

Yes

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First name

Last name

Email address

Date of birth (MM/DD/YYYY)

You must be at least 18 years old.

ZIP Code

You must reside in the US or Puerto Rico.

By providing your information and clicking “Enroll Now”, you acknowledge and agree that Sumitomo Pharma America and its affiliates, vendors, business partners, and agents will receive and process your personal information, including the health information you provide, to administer and operate the copay program, to communicate with you as selected above, and as otherwise described in our Privacy Policy. If you would like to withdraw your consent or exercise any rights in respect of your personal information, please contact us as described in the Privacy Policy.

You certify that you are at least 18 years old and that the information provided above is true and correct and that you are not enrolled in a federal or state-funded prescription drug benefit program, such as Medicare or 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.

You agree that you have read, understand, and agree with the ORGOVYX Copay Assistance Program Terms, Conditions, and Eligibility Criteria our Terms of Use.

By activating your card, you certify that the information provided above is true and correct and that you are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare or 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.

Sign up for Copay Assistance from ORGOVYX

Do you have commercial prescription drug insurance?

What should I tell my healthcare provider before taking ORGOVYX?

What are the possible side effects of ORGOVYX?

What is ORGOVYX?

Sign up for Copay Assistance from ORGOVYX

Do you have commercial prescription drug insurance?

What should I tell my healthcare provider before taking ORGOVYX?

What are the possible side effects of ORGOVYX?

What is ORGOVYX?

Indication

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