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residents aged 18 and older.

Prescribing Information

Register for a new card by filling out and submitting the form below.
You could pay
$10 a month
For Bystolic with a 90-day prescription
That's just 33 cents a day!
Talk to your doctor today about potentially saving more with a 90-day prescription.

Register for a new card by filling out and submitting the form below.
Step 1 of 2: Registration

You certify that the information provided above is true and correct. In addition, by providing your email address, you agree that you would like to receive information from Allergan related to BYSTOLIC® and the BYSTOLIC® Savings Program, including site updates, education, and other Allergan products and services. The information pertaining to you that we collect will be used in accordance with our Privacy Statement.

Get your E-Savings Card and reminders about when to refill and pick up your BYSTOLIC prescription delivered to your mobile phone.

By checking this box and by providing your mobile phone number, you agree that Allergan may text you information about BYSTOLIC® and the BYSTOLIC® Savings Program, including site updates, education, and other Allergan products and services, to your mobile device. You also understand that you may receive an average of 6 messages per month, that message and data rates may apply and that any message sent to your mobile device may be an unsecured communication. If you later wish to opt out from receiving this information, you understand that you can unsubscribe at any time by simply texting "STOP" to 855.827.8729 and receive help by texting "HELP" to 855.827.8729. The information pertaining to you that we collect will be used in accordance with our Privacy Statement.

Step 2 of 2: Authorization
AUTHORIZATION FOR USE AND RELEASE OF PROTECTED HEALTH INFORMATION
Bystolic® Patient Savings Program

I authorize Allergan and its contractors and business partners ("Allergan") to use and/or disclose my personal information, including my personal health information, for the following purposes: (1) to operate, administer, enroll me in, and/or continue my participation in the BYSTOLIC® Patient Savings Program and/or any other Allergan-affiliated patient support services and activities related to my condition or treatment (for example, co-pay card programs if eligible, reimbursement assistance programs, drug coverage verification, health care provider educator services, adherence programs, and disease management support); (2) to contact my doctor and the rest of my health care providers and share with them my health information that may be useful for my care; (3) to provide me with informational and promotional materials relating to Allergan products and services, and/or my condition or treatment; and/or (4) to improve, develop, evaluate, and continue Allergan products, services, materials, and programs related to my condition or treatment.

In order for Allergan to provide the above services and programs to me, I understand that Allergan will need my personal information and my health information, which may include my name, address, email address, information about my health condition, my treatment and product information, treatment dates, eligible treatment type, my medical history and general health, my health care plan benefits and coverage, information about my adherence to my treatment, and other relevant personal and health information ("Personal Health Information"). I authorize my health care providers, including my doctor's office, pharmacies, health plans, laboratory services, and other healthcare providers, and all employees, individuals, and entities working with or for such health care providers ("Health Care Providers") who have my Personal Health Information to release and disclose my Personal Health Information to Allergan only for the purposes set forth above, including providing me with the BYSTOLIC® Patient Savings Program.

I understand that some of my Health Care Providers (such as pharmacies and specialty pharmacies) may receive remuneration from Allergan in exchange for disclosing my Personal Health Information and/or for using my information to contact me with communications about Allergan products that have been prescribed to me and other patient support services.

My Health Care Providers may release my Personal Health Information in whatever form and through whatever media, including the internet, as required by the purposes set forth.

I further understand that once my Health Care Providers disclose my Personal Health Information to Allergan, it may no longer be covered by federal privacy regulations, and, therefore, could be re-disclosed. However, Allergan agrees to protect my Personal Health Information by only using and disclosing it as stated in this Authorization or as otherwise allowed or required by law.

I understand that I may receive a copy of this authorization or revoke this authorization at any time by calling 1 (800) 572 - 5252. However, if I revoke this authorization, I understand I may no longer qualify for the BYSTOLIC® Patient Savings Program and/or the other services described above. I further understand that if a Health Care Provider is disclosing my Personal Health Information to Allergan, my revocation of this authorization will only prevent further disclosure of my Personal Health Information to Allergan by such Health Care Providers after they receive notice of my revocation.

I understand that this authorization is voluntary and I may refuse to sign it. My refusal to sign will not affect my ability to obtain treatment or payment for my treatment. But, I may be ineligible to qualify for the BYSTOLIC® Patient Savings Program and the other programs and services set forth above.

I understand that this authorization for my Health Care Providers to disclose my Personal Health Information will not expire unless I notify Allergan to terminate it, or unless another date is specified herein, or is required by state or other applicable law(s).

Electronic Authorization:

I understand that by clicking the "I accept" button below, that I am consenting electronically and providing legal authorization for Allergan, including any affiliates, subcontractors, and/or agents of Allergan (such as vendors operating the BYSTOLIC® Patient Savings Program) to use and share, and for my Health Care Providers to disclose, my Personal Health Information for the purposes described within the above authorization. I am also indicating that I am at least 18 years old and either the patient or legal guardian of the patient by clicking the "I accept" button.

Please click here for full Prescribing Information for BYSTOLIC.

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Terms, Conditions, and Eligibility Criteria: 1. This offer is valid only for patients 18 years of age or older with commercial prescription drug insurance and is good for use only with a valid prescription for BYSTOLIC® (nebivolol) 2.5 mg, 5 mg, 10 mg, and/or 20 mg tablets at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. Depending on your insurance coverage, most eligible insured patients may pay no more than $30 (a) per 30-day supply for each of up to twelve (12) prescription fills, (b) per 60-day supply for each of up to six (6) prescription fills, or (c) per 90-day supply for each of up to four (4) prescription fills. Other eligible insured patients check with your pharmacist for your copay discount. Maximum reimbursement limits apply; patient out-of-pocket expense may vary. 3. This card is not valid for prescriptions submitted for reimbursement to Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. 4. Each card is valid for up to 12 prescription fills of a 30-day supply, or 12 monthly uses. A 60-day supply counts as two (2) monthly uses and a 90-day supply counts as three (3) monthly uses towards the 12-monthly-use limit. Offer applies only to prescriptions filled before the program expires on 12/31/17. 5. Allergan reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA at participating retail pharmacies. 7. Void if prohibited by law, taxed, or restricted. 8. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 9. This card has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. 10. This offer is not health insurance. 11. This card expires December 31, 2017. 12. By redeeming this card, you acknowledge that you are an eligible insured patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about the program, including savings on mail-order prescriptions, please call 1.800.572.5252.

Pharmacist Instructions for a Patient with an Eligible Third-party Payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription. Submit the claim to the primary Third-party Payer first, then submit the balance due to Change Healthcare using BIN #637765 as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 3 or 8). The patient’s out-of-pocket expense will be reduced up to the maximum reimbursement limit for the program. Reimbursement will be received from Change Healthcare. For any questions regarding online processing, call the Help Desk at 1.866.440.3808.

Program managed by COMP, LLC on behalf of Allergan. This is not insurance.

Mail Order Patients:

If you fill your prescription through a mail-order pharmacy, or if you are unable to have your savings card processed at your local pharmacy, please submit:

  • A photocopy of the front and back of your BYSTOLIC® Savings Card.
  • Your original proof of purchase (original pharmacy receipt with your name and address, pharmacy name, product name, prescription numbers, NDC number, date filled, quantity, and price).
  • A photocopy of the front and back of your insurance card.
  • Your date of birth.

Mail all of the information to:

BYSTOLIC® Claims Processing Department,
P.O. Box 1785
New York, NY 10156

Please allow 6-8 weeks to receive your reimbursement. Reimbursement requests must be postmarked within 4 weeks of fill date. Reimbursements are subject to Program Terms, Conditions, and Eligibility Criteria.