MyIgSource Enrollment

MyIgSource offers complimentary tools and resources for patients and families. Enroll today for ongoing support.

All fields are required for enrollment.

Call 1-855-250-5111 to enroll by phone in MyIgSource.

*indicates required field

Gammagard Liquid MyIgCoPayCard Program Terms and Conditions

This manufacturer's coupon program is not valid for prescriptions reimbursed, in whole or in part, by Medicaid, Medicare, Medigap, VA, DoD, TRICARE, or any other federal or state healthcare programs, including state pharmaceutical assistance programs, and where prohibited by the health insurance provider or by law

Shire's MyIgCoPayCard program provides a maximum total benefit of $5,000 for eligible out-of-pocket costs and expires 12 months from date of activation. Eligible costs include deductible, copayment, and co-insurance costs for eligible Shire IG (Immunoglobulin) products. Non-medication expenses, such as ancillary supplies or administration-related costs, are not eligible.

To be eligible, patients must: 1. be starting or receiving treatment with (and have current prescription for) an eligible Shire IG product with an ICD-10 for a diagnosis of Primary Immunodeficiency; and 2. have commercial insurance that covers medication costs for prescribed Shire IG product and allows for CoPay assistance; and 3. be two (2) years old or older.

Acceptance of this offer must be consistent with the terms of benefits provided by patient's health insurance provider.

Offer limited to one card per person and may not be combined with any other coupon, discount, prescription savings card, rebate, free trial, patient assistance, or other offer.

This program is only valid for residents of the United States.

Shire reserves the right to change or discontinue this program at any time without notice.

This is not health insurance.

-----

Add to patient instructions:

If your insurance situation changes, it is your responsibility to notify MyIgSource's CoPay assistance program.


© 2017 Shire. All rights reserved.

SHIRE and the Shire Logo are registered trademarks of Shire Pharmaceutical Holdings Ireland Limited or its affiliates. Gammagard Liquid is a trademark or registered trademark of Baxalta Incorporated, a wholly owned, indirect subsidiary of Shire plc.

S30515 04/17

Please expand for Indication and Important Safety Information.

Selected Important Safety Information for GAMMAGARD LIQUID
  • GAMMAGARD LIQUID can cause decreased kidney function or kidney failure, blood clots in the heart, brain, lungs or elsewhere in the body. Call your healthcare professional or go to your emergency department right away if you have: Reduced urination, sudden weight gain, or swelling in your legs. These could be signs of a kidney problem. Pain, swelling, warmth, redness, or a lump in your legs or arms. These could be signs of a blood clot.
  • Do not take GAMMAGARD LIQUID if you have a known history of a severe allergic reaction to IgG or other blood products.

Terms and Conditions

Patient instructions

  1. By using this coupon, you are certifying that:
  2. 1) You meet the eligibility criteria and have read and agree to the terms and conditions of this manufacturer coupon program;
  3. 2) You will not, at any time, submit any costs for the product dispensed pursuant to this coupon to any government healthcare program for reimbursement;
  4. 3) You are permitting your personal information, including name, address, phone number, email address, and information related to health insurance and treatment, to be shared with Shire and companies working with Shire for the purpose of administering this program; and
  5. 4) You will notify your health insurance provider or other third-party payer of the use of this coupon if required to do so.
  6. For questions about this program, patients and caregivers can call the GAMMAGARD Patient Support Program at (855) 250-5111.

Pharmacy instructions

  1. By submitting a claim for reimbursement pursuant to this manufacturer coupon program, the Pharmacy represents and warrants that:
  2. 1) It has dispensed GAMMAGARD LIQUID treatment to an eligible patient and in accordance with the terms and conditions of this program and the accompanying prescription;
  3. 2) Its participation in this program is consistent with all applicable laws and any obligations, including its contract with the applicable payer;
  4. 3) It will report coupon assistance received to payers; and
  5. 4) The entire benefit amount received will go to eligible expenses and it will not retain any portion of the benefit as payment to it for administration or ineligible expenses.
  6. For questions regarding processing, claim transmission, patient eligibility, or other issues, pharmacists can call the GAMMAGARD LIQUID SubQ CoPay Card Program administrators at (855) 217-1615.