By enrolling in the Free Trial Offer Program, you acknowledge that your patient currently meets the eligibility criteria and will comply with the terms and conditions described below:
The KRAZATI® Free Trial Offer Program provides eligible patients with a 30-day supply of KRAZATI® at no cost
The KRAZATI® Free Trial Offer Program is solely intended to allow new patients a free trial of KRAZATI® to determine, with you, whether KRAZATI® is right for them. This Free Trial Offer is valid for one time only with no refills. For any future use, you must write a new prescription for KRAZATI®
To be eligible, a patient must (1) have an on-label diagnosis, (2) be new to KRAZATI® treatment, (3) not have enrolled previously in the KRAZATI® Free Trial Offer Program, and (4) be 18 years of age or older
The KRAZATI® Free Trial Offer Program supply will be delivered to the patient’s preferred address (no P.O. Boxes)
The KRAZATI® Free Trial Offer Program supply cannot be exported or transferred in exchange for money, other property, or services
No portion of the KRAZATI® Free Trial Offer Program may be submitted for reimbursement to any third-party payer, including Medicare or Medicaid, either directly or indirectly
The KRAZATI® Free Trial Offer Program is not health insurance. This free trial offer is not intended to address delays or gaps in health insurance coverage for the specified prescription
This program is for one free 30-day supply per patient (per lifetime)
This program is valid only for residents of the United States and U.S. territories
The Mirati & Me Patient Support Program reserves the right to rescind, revoke, or amend this program at any time without notice
Void where prohibited by law. Void where use is prohibited by the patient’s insurance provider