Terms and Conditions

Coupon Program

Eligible patients can pay as little as $35 for XYREM for a 30-day fill, subject to monthly and annual maximum benefit. The Coupon Program is only available for residents of the US, Puerto Rico, and the other US territories who have commercial insurance with out-of-pocket expenses, including co-pay/co-insurance/plan deductibles exceeding $35 (for XYREM) per 30-day prescription fill. The Coupon Program is for commercially insured patients that have been prescribed XYREM. The XYREM Coupon Program is not valid for beneficiaries of Medicare, Medicaid, VA, or other federal or state healthcare programs, if you pay for your prescription in cash or if you choose not to use your insurance coverage. The Coupon Program requires a valid, signed prescription for XYREM. The Coupon Program is for patients enrolled in the XYREM and XYREM REMS. The pharmacy will bill your insurance for the portion that your insurance plan has agreed to cover. The XYREM Coupon Program is not health insurance. The pharmacy, patient, or prescriber cannot submit a claim for reimbursement under any federal, state, or other governmental programs or any third party for any part of the benefit received by the patient through the Coupon Program. By using this offer, patients certify that they will comply with any terms of their health insurance contract requiring notification to their payor of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is non-transferrable. This offer is void where prohibited by law. No purchase necessary. The Coupon may not be applied retroactively. If your insurance changes, you must inform the pharmacy immediately. Based on your insurance change, you may no longer be able to participate in the XYREM Coupon Program. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time and without notice and in its sole discretion. In order to facilitate the XYREM Coupon Program, you understand and agree that Jazz will process your personal information in accordance to Jazz Pharmaceuticals’ Privacy Policy which can be found at www.jazzcares.com.

Quick Start Voucher

The voucher is good for up to one-month’s free supply (maximum of three bottles) for a patient’s first-time shipment. There is a lifetime limit of one voucher per patient. The voucher is for commercially insured patients that have been prescribed XYREM for its FDA-approved indications. The voucher is only available for residents of the US, Puerto Rico, and the other US territories. The voucher is not valid for beneficiaries of Medicare, Medicaid, VA, or other federal or state healthcare programs. The voucher requires a valid, signed prescription for XYREM. The voucher is for patients enrolled in the XYREM and XYREM REMS. The voucher is for patients that are experiencing an insurance coverage decision delay greater than 10 calendar days for XYREM or for patients changing from XYREM who are at risk of therapy interruption (i.e., less than seven calendar days from the patient’s next XYREM delivery date). The voucher may not be submitted by the patient, pharmacy, or prescriber to seek reimbursement for all or any part of the benefit received by the patient through this voucher. The free supply of XYREM cannot be used toward any out-of-pocket costs under any health insurance or prescription drug plan. The voucher may not be applied retroactively and does not cover refills. The voucher cannot be combined with any other voucher, certificate, coupon, rebate, or similar offer. Use of the voucher is not contingent on any purchase requirement. This is not a discount, rebate, or insurance program. The voucher is not valid where otherwise prohibited by law. It is illegal for any person to sell, purchase, trade, or counterfeit the voucher. Jazz Pharmaceuticals reserves the right to terminate or modify this program any time with or without notice. In order to facilitate the XYREM Quick Start Voucher, you understand and agree that Jazz will process your personal information in accordance to Jazz Pharmaceuticals’ Privacy Policy which can be found at www.jazzcares.com.

Bridge Program

The Bridge Program is for patients who have commercial insurance that are at risk of therapy interruption due to a change in insurance or change in insurance coverage for XYREM. The Bridge Program benefit is a free drug offer valid for up to a one hundred and twenty (120) day supply of XYREM or until commercial insurance coverage has been established or you have transitioned to a different therapy or discontinued therapy, whichever comes first, given in up to fifteen (15) day increments. The Bridge Program is only available for residents of the US, Puerto Rico, and the other US territories. The Bridge Program is for patients that have been prescribed XYREM for its FDA-approved indications. The Bridge Program is not valid for beneficiaries of Medicare, Medicaid, VA, or other federal or state healthcare programs, if you pay for your prescription in cash or if you choose not to use your insurance coverage. The Bridge Program requires a valid, signed prescription for XYREM. The Bridge Program is for patients enrolled in the XYREM and XYREM REMS. The Bridge Program is not health insurance. The pharmacy, patient, or prescriber cannot submit a claim for reimbursement under any federal, state, or other governmental programs or any third party for any part of the benefit received by the patient through the Bridge Program. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is non-transferrable. This offer is void where prohibited by law. No purchase necessary. If your insurance changes, you must inform the pharmacy immediately. Based on your insurance change, you may no longer be able to participate in the XYREM Bridge Program. Jazz Pharmaceuticals reserves the right to terminate or modify this program at any time and without notice and in its sole discretion.

Patient Assistance Program

Terms and Conditions apply.