Fill out the form below to activate your card. Use the ID number for the OxyContin Savings Card and enter each of the form fields.
Patient is not eligible if prescriptions are paid in part or in full by (i) any federal or state healthcare program, including a state medical or pharmaceutical assistance program (Medicare, Medicaid, Medigap, VA, DOD, TRICARE, etc), (ii) Medicare Prescription Drug Program (Part D Program), or (iii) insurance in states that have an "all payer" anti-kickback law or insurance that is paying the entire cost of the prescription.
The personal information that you provide will be kept confidential and will not be shared with third-party processing agents other than Purdue Pharma L.P. and its designated parties. You understand and agree that the information you provide as well as the information obtained about you from the pharmacy, will be shared with the manufacturer and any companies working with the manufacturer. For more information on OxyContin, please visit www.OxyContin.com where you will find a copy of the Full Prescribing Information, including the Boxed Warning and the Medication Guide.
Your card is not valid for prescriptions purchased under Medicaid, Medicare or similar federal, state or other government-funded benefit programs. Not valid where prohibited by law. Should you begin receiving prescription benefits from such a federal, state or government-funded program at any time, you will no longer be eligible to participate in the OxyContin Patient Savings Program. We may contact you by phone or mail periodically in order to verify that your eligibility for the program has not changed. Do you acknowledge your agreement with this statement?