Z-Save® Patient Support Program

As a member of the program, you'll receive the ZENPEP Savings Card. With the savings card, eligible patients pay as little as $0 for their first prescription fill and as little as $30 for refills.* The program offers:

Discounted out-of-pocket costs: eligible patients may pay as little as $0 for their first prescription fill and as little as $30 for refills.*

Your choice of Pure Encapsulations® Nutrient 950® with Vitamin K or Pure Encapsulations® Nutrient 950® without Iron (or Vitamin K)^†

Your choice of nutritional supplements: Boost Plus® Vanilla or Boost Plus® Rich Chocolate

Refill, dosage, and administration reminders

Live support from customer care advocates

* Please see full program terms and conditions.

^† Please consult with your healthcare professional before beginning nutritional supplements.

Step 1:
AUTHORIZATION
Step 2:
REGISTRATION AND ACTIVATION
Step 3:
CONFIRMATION

I authorize Nestlé Health Science and its contractors and business partners ("Nestlé Health Science") 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 ZENPEP Patient Support Program and/or any other Nestlé Health Science-affiliated patient support services and activities related to my condition or treatment (for example, copay card programs if eligible, reimbursement assistance programs, drug coverage verification, healthcare provider educator services, adherence programs, and disease management support); (2) to provide me with informational and promotional materials relating to Nestlé Health Science products and services, and/or my condition or treatment; and/or (3) to improve, develop, evaluate, and continue Nestlé Health Science products, services, materials, and programs related to my condition or treatment.

In order for Nestlé Health Science to provide the above services and programs to me, I understand that Nestlé Health Science 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 healthcare plan benefits and coverage, information about my adherence to my treatment, and other relevant personal and health information ("Personal Health Information"). I authorize my healthcare 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 healthcare providers ("Healthcare Providers") who have my Personal Health Information to release and disclose my Personal Health Information to Nestlé Health Science only for the purposes set forth above, including providing me with the ZENPEP Patient Support Program.

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

My Healthcare 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 Healthcare Providers disclose my Personal Health Information to Nestlé Health Science, it may no longer be covered by federal privacy regulations, and, therefore, could be re-disclosed. However, Nestlé Health Science 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 (866) 800-8082. However, if I revoke this authorization, I understand I may no longer qualify for the ZENPEP Patient Support Program and/or the other services described above. I further understand that if a Healthcare Provider is disclosing my Personal Health Information to Nestlé Health Science, my revocation of this authorization will only prevent further disclosure of my Personal Health Information to Nestlé Health Science by such Healthcare 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 ZENPEP Patient Support Program and the other programs and services set forth above.

I understand that this authorization for my Healthcare Providers to disclose my Personal Health Information will not expire unless I notify Nestlé Health Science 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, I am consenting electronically and providing legal authorization for Nestlé Health Science, including any affiliates, subcontractors, and/or agents of Nestlé Health Science (such as vendors operating the ZENPEP Patient Support Program) to use and share, and for my Healthcare 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.

I understand

First name

Last name

Email address

Verify email address

Address line 1 (vitamins and supplements cannot be shipped to a P.O. Box)

Address line 2 (vitamins and supplements cannot be shipped to a P.O. Box)

City

State

ZIP code

Date of birth (MM/DD/YYYY)

Sex

Male

Female

Are you a resident of the United States or Puerto Rico?

Yes

Do you have commercial prescription drug insurance?

Yes

Do you currently have a ZENPEP Savings Card?

Yes

Savings card number

Vitamin selection

By selecting the vitamin option below, I acknowledge that a doctor has been consulted about the vitamins offered through the ZENPEP Patient Support Program.

No, thank you

Pure Encapsulations^® Nutrient 950^® with Vitamin K

Pure Encapsulations^® Nutrient 950^® without Iron (or Vitamin K)

Supplement selection

By selecting the supplement option below, I acknowledge that a doctor has been consulted about the supplements offered through the ZENPEP Patient Support Program.

No, thank you

Boost Plus^® Vanilla

Boost Plus^® Rich Chocolate

Method of contact

I prefer not to receive refill reminders

Email updates

By providing your email address, you agree that you would like to receive information from Nestlé Health Science related to ZENPEP and the ZENPEP Patient Support Program, including site updates, education, and other Nestlé Health Science products and services. The information pertaining to you that we collect will be used in accordance with our Privacy Policy. If you later wish to opt out from receiving this information, you may click on the included opt-out link in future communications.

No, I do not agree

Yes, I agree

By activating the card and enrolling in the ZENPEP Patient Support Program, you certify you have commercial prescription drug insurance and are not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses you for the entire cost of your prescription drugs. You also certify that you are not Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. You further certify that should you begin receiving prescription benefits from one of these programs at any time, you will no longer participate in the ZENPEP Patient Support Program.

I agree to this certification and accept the program terms, conditions, and eligibility criteria available here or on back of card.

Program Terms, Conditions, and Eligibility Criteria:

This offer is good for use only with a valid prescription for ZENPEP® (pancrelipase) Delayed-Release Capsules at the time the prescription is filled by the pharmacist and dispensed to the patient.
Depending on your insurance coverage, most eligible patients may pay as little as $0 for the first ZENPEP prescription and $30 for each refill of ZENPEP. Check with your pharmacist for your copay discount. Maximum savings limit applies; patient out-of-pocket expense may vary.
This offer is not valid for use by patients enrolled in, nor shall the copay prescription be submitted for reimbursement to, Medicare (including Medicare Advantage), Medicaid (including managed Medicaid plans), Medigap, TRICARE, 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. This offer is not valid for cash-paying patients.
This offer is valid for up to twelve (12) prescription fills of a 30-day supply or up to four (4) prescription fills for a 90-day supply. Offer applies only to prescriptions filled before the program expires on December 31, 2024.
Nestlé reserves the right to rescind, revoke, or amend this offer without notice.
Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.
For California and Massachusetts residents, benefits pursuant to this card will terminate automatically upon the introduction of a therapeutically equivalent product.
Void if prohibited by law, taxed, or restricted.
This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.
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.
This offer is not health insurance.
This card expires December 31, 2024.
Certain information related to your use of the card may be collected, analyzed, and shared with Nestlé for market research and other purposes related to assess Nestlé’s programs. Information shared with Nestlé will be aggregated and deidentified; it will be combined with other data related to other card redemptions and will not identify you. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about the program, please call 1-833-742-0707.

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 PDMI using BIN# 610020 as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code (eg, 8). If you receive a rejection due to PA, step-edit, or NDC block, submit Other Coverage Code of 03 (secondary claim). The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from PDMI. For help processing this card, call 1-833-742-0707. Representatives are available Monday through Friday, 8AM–8PM EST, except for major holidays.

Program managed by TrialCard on behalf of Nestlé Health Science.

ADDRESS VERIFICATION

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