Welcome to the XCOPRI® Savings Card.

The XCOPRI Savings Card may help eligible patients save on their copay. Enrolling is quick and easy for patients, with just a few questions to determine if they qualify.

PATIENT ELIGIBILITY

Are you a resident of the United States or Puerto Rico?

Yes

Please select Yes or No

We’re sorry. Based on the information provided, you are not eligible for the XCOPRI Savings Card. If you have questions, please contact the XCOPRI Savings Card at 1-844-558-2648.

Are you currently enrolled in, or eligible for, a federal or state-funded healthcare program? This includes, but is not limited to, Medicare (Parts A, B, C, or D), Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DoD), or TRICARE.

Yes

Please select Yes or No

We’re sorry. Based on the information provided, you are not eligible for the XCOPRI Savings Card. If you have questions, please contact the XCOPRI Savings Card at 1-844-558-2648.

Do you have private commercial health insurance? This includes plans purchased through state or federal health insurance marketplaces/exchanges.

Yes

Please select Yes or No

We’re sorry. Based on the information provided, you are not eligible for the XCOPRI Savings Card. If you have questions, please contact the XCOPRI Savings Card at 1-844-558-2648.

First Name

Please enter First Name

Last Name

Please enter Last Name

Email (optional)

Please enter a valid Email Address

If you provide an email address, a copy of your XCOPRI Savings Card will be emailed to you.

Mobile Number (optional)

Please enter a valid Mobile Number

Date of Birth

Please enter Date of Birth

ZIP Code

Please enter valid ZIP Code

Gender

Please select Gender

I authorize my healthcare providers, pharmacies, health plans, insurers, pharmacy benefit managers, and other persons or entities that possess information about me to disclose to SK Life Science, Inc. (“SKLSI”), ConnectiveRx, and other service providers administering the XCOPRI® Savings Card on SKLSI’s behalf information about my identity, contact information, XCOPRI prescription, insurance coverage, prescription drug benefits, claims, and Card eligibility.

I authorize SKLSI, ConnectiveRx, and the Card’s other service providers to use and disclose this information as necessary to: (1) enroll me in and administer the XCOPRI Savings Card; (2) verify my insurance coverage, prescription drug benefits, Program eligibility, and potential out-of-pocket costs; (3) communicate with my healthcare providers, pharmacies, health plans, insurers, and pharmacy benefit managers; (4) process, investigate, reconcile, and audit Card transactions; (5) contact me about the Card and the services I request; and (6) obtain information or follow up regarding any adverse event, product complaint, or other safety information.

I understand that SKLSI may compensate ConnectiveRx and other service providers for administering the Card. I understand that information disclosed to SKLSI or its service providers may no longer be protected by federal health-information privacy law and may be redisclosed, although SKLSI and its service providers intend to use and disclose it only as described in this authorization or as permitted or required by law.

Please check box

XCOPRI® Savings Card Terms & Conditions

Patient must have a valid prescription for XCOPRI® (cenobamate tablets) CV.
Patient must have commercial prescription drug insurance.
Patient must not have prescription drug coverage, in whole or in part, through any federal, state, or other government-funded healthcare program, including but not limited to Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medigap, TRICARE, Veterans Affairs (VA), Department of Defense (DoD), CHAMPVA, or any other federal or state healthcare program.
Patients with secondary government insurance coverage are not eligible, even if commercial insurance is the patient’s primary insurance.
Uninsured and cash-paying patients are not eligible for the XCOPRI® Savings Card.
Patient must reside in the United States or a U.S. territory where the XCOPRI® Savings Card is offered.
Patient and prescription must otherwise satisfy all XCOPRI® Savings Card requirements at the time the benefit is redeemed.
Eligible patients are automatically enrolled in the XCOPRI® Savings Card upon successful registration and eligibility verification. XCOPRI® Savings Card benefits are valid through December 31 of the applicable calendar year, unless the XCOPRI® Savings Card is terminated or modified earlier in accordance with these Terms and Conditions.
The XCOPRI® Savings Card is not health insurance, does not provide insurance coverage or benefits, and does not replace or supplement a patient’s health insurance or prescription drug coverage.
The XCOPRI® Savings Card and any XCOPRI® Savings Card benefits are nontransferable and have no cash value. The Savings Card may not be sold, purchased, traded, assigned, or otherwise transferred to another individual.
SK Life Science, Inc. reserves the right to modify, suspend, or terminate the XCOPRI® Savings Card, including its eligibility requirements, benefits, and Terms and Conditions, at any time, with or without notice, subject to applicable law.

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Welcome to the XCOPRI® Savings Card.

XCOPRI® Savings Card Terms & Conditions

Already Enrolled