Enroll in the Rezdiffra Copay Savings Program. 

MADRIGAL PATIENT SUPPORT

Success!

You have been successfully enrolled in the Rezdiffra Copay Program.

Let’s get you enrolled.

Fill out this form to enroll in the copay program and capture the secure authorization needed for program support.

Eligibility

*Indicates a required field.

*Do you have commercial insurance that covers Rezdiffra?

YesNo

*Are you enrolled in a state or federally funded prescription insurance program? This includes enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs, or TriCare.

YesNo

*Do you currently live in the US or US territories?

YesNo

*Are you 18 years of age or older?

YesNo

Patient information

*Indicates a required field.

*Patient First Name

*Patient Last Name

*Patient Address

*Patient City

*Patient State

*Patient ZIP Code

*Patient Date of Birth

*Patient Mobile Number

*Patient Email

*Rezdiffra Copay Program Consent

By checking the box, I agree that Madrigal Pharmaceuticals, Inc., its affiliates, services providers, and companies working with us, will need to use and share personal and contact information to administer the Rezdiffra Copay Program. I agree to Madrigal Privacy Policy and Rezdiffra Copay Program Terms and Conditions. I understand that I may withdraw my consent at any time by emailing [email protected]. I agree to receive by mail, telephone or email, or, if I indicate my agreement and consent below, by text, marketing and promotional communications and other information from Madrigal including health-related resources and therapy information (the “Communications”). Madrigal or third parties working on its behalf will not sell my personal information. If, in the future, I no longer want to receive health-related materials, I may opt out at any time by following the instructions in the communication.

Madrigal Text Consent

I acknowledge that by checking here, I expressly consent to receive text messages from or on behalf of Madrigal at the mobile telephone number(s) that I provide. I understand that my wireless service provider’ s message and data rates may apply and that I can opt out of future text messages at any time by following the opt-out instructions contained in any text message communications.

Prescriber Information

*Indicates a required field.

*Prescriber Name

Prescriber Address

Prescriber City

Prescriber State

Prescriber ZIP Code

Prescriber Phone Number

Pharmacy Information

Was your prescription sent to a pharmacy?

YesNo

Please provide the pharmacy name (if known):

Provide authorization for assistance

*Indicates a required field.

To complete your enrollment in the Copay Savings Program, we’ll need your consent to participate in Madrigal Patient Support by signing the authorization form below.

Madrigal Patient Support is provided at no cost and offers eligible patients:

• Help identifying financial assistance options
• Support getting started and throughout treatment
• Education and tips from Nurse Navigators

Please review the information below and sign the form to continue.

Please print or write down the information on the card below. You will need to provide this information to the pharmacy that will be dispensing Rezdiffra.

Print your card

We’re Sorry!

Unfortunately, you are not eligible to participate in this program.

There may be other financial assistance programs available to you. If you need more information or want to discuss eligibility, please contact Madrigal Patient Support at 1-877-219-7770, 8AM - 8PM ET, Monday through Friday.

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1-844-309-1102

ELIGIBILITY

Patient must have commercial insurance and the insurance does not cover the full cost of the prescription
Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs, or TriCare
Not valid to cash-paying patients
Must reside in the US or US territory
Must be 18 years of age or older

Eligible commercially insured patients with a valid prescription may pay as little as [$0] per month. Patient out-of-pocket expense may vary. Patients is responsible for applicable taxes, if any
The Rezdiffra Copay Program may have a monthly and annual cap which will be determined by the program sponsor and is subject to change at any time
Enrollment in the Rezdiffra Copay Program is valid for 12 months
Patient has a valid prescription for Rezdiffra
Other restrictions may apply. Patient is responsible for applicable taxes, if any
Nontransferable, limited to one per person, cannot be combined with any other offer
Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer
Madrigal reserves the right to rescind, revoke, or amend this offer, eligibility, and terms of use at any time without notice
This offer is not conditioned on any past, present, or future purchase, including refills
This offer is not health insurance
Certain information pertaining to your use of the Rezdiffra Copay Program will be shared with Madrigal Pharmaceuticals, the sponsor of the Rezdiffra Copay Program. The information disclosed will include the date the prescription is filled, the number of pills or product dispensed by the pharmacists, and the amount of your copay that will be paid for by using this Rezdiffra Copay Program. For more information, please see the Madrigal Privacy Policy at www.madrigalpharma.com
BY REDEEMING THIS OFFER, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE