SUPPORTING YOUR TREATMENT JOURNEY EVERY STEP OF THE WAY

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Pay as little as $0 for ROMVIMZA, if eligible*

ROMVIMZA™ copay card
*For commercial insurance only. See full terms and conditions.

Complete this form to obtain your Copay Card information.

  • I have read and agree to the full Eligibility Criteria and Terms & Conditions below
  • I am commercially insured
  • I am not receiving benefits under Medicaid, a Medicare drug benefit plan, TRICARE, or another federal or state health program
  • I am 18 years of age or older
  • I am a resident of the U.S. or Puerto Rico
  • I agree to report the receipt of all Program benefits as may be required by my insurance provider
  • I will not seek reimbursement for all or any of the benefit received through this Program

Eligibility Criteria
and Terms & Conditions

By using this Deciphera Commercial Copay Program co-pay card, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below: Offer cannot be combined with any other offer. Offer valid only in the United States, and Puerto Rico. This copay offer is prohibited for prescriptions that do not qualify for reimbursement under the patient's commercial or private prescription insurance plan. Patients must not seek reimbursement from any health savings, flexible spending, or other healthcare reimbursement accounts for the amount of assistance received from the Program. This copay offer is prohibited for prescriptions reimbursed in whole or in part by Medicaid, Medicare, or any similar federal or state healthcare program, including any state medical or pharmaceutical assistance program. The discount provided by this copay offer must not exceed the amount of an individual's copayment under any federal or state program. This copay offer is not insurance. Acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value of the copay assistance you receive as may be required by your insurance provider. This copay offer is redeemable by Deciphera, who reserves the right to rescind, revoke or amend this offer without notice. The selling, purchasing, trading, or counterfeiting of this copay offer is prohibited. This offer is also invalid where prohibited by law. If you are assisting a patient in submitting information through this website, you acknowledge and agree that you have the patient’s consent and authorization to submit this information on the patient’s behalf for the purposes of applying for the Deciphera Commercial Copay Program. Benefit subject to annual maximum. Patients to be provided with full terms and conditions, including benefit maximum, after enrollment. Important Information: By downloading this card, you are enrolling in the Deciphera Commercial Copay Program. Deciphera, its affiliates, collaborators and agents will use this information to provide the Patient support and perform research and analytics, on a de-identified basis, for management of the program. For more information visit, https://www.deciphera.com/privacy-policy.

Patient Copay Program enrollment form

*Required fields

By checking this box, I authorize my health care providers and staff, my pharmacies, and my health insurers to use and to disclose to Deciphera Pharmaceuticals, and its affiliates, business partners, vendors, and other agents (collectively, “Deciphera”) health information about me, including information related to my medical condition and treatment, health insurance and coverage claims, and prescription (including fill/refill information) for ROMVIMZA (my “Information”) to (1) enroll me in and provide services under the Deciphera Commercial Copay Program for ROMVIMZA (the “Program”); and (2) contact me to conduct market research and to arrange for my receipt of educational, promotional, and/or marketing materials about Deciphera support programs or Deciphera products. Once my information has been disclosed to Deciphera, I understand that federal privacy laws may no longer protect it from further disclosure. However, I also understand that Deciphera will protect my Information by using and disclosing it only for the purposes allowed by me in this Authorization or as otherwise required by law. I understand and agree that the pharmacy that dispenses my ROMVIMZA may receive payment from Deciphera in exchange for disclosing my Information to Deciphera and providing Program services.

I understand that I do not have to sign this Authorization. A decision by me not to sign this Authorization will not affect my ability to obtain medical treatment from my health care providers, my eligibility for health insurance benefits, or my access to Deciphera medications. However, if I do not sign this Authorization, I understand I will not be able to participate in the Program. I understand that this Authorization expires ten years from the date signed below, or as otherwise required by state or local law, unless and until I cancel (take back) this Authorization before then. I may change my mind and cancel this Authorization at any time by calling 1‑800‑364‑4767 or by notifying Deciphera in writing at IQVIA: 430 Mountain Avenue, Suite 105, New Providence, NJ 07974. Cancellation of this Authorization will end further uses and disclosures of my Information and my participation in the Program but will not affect any uses or disclosure of my information made by my health care providers and staff, my pharmacies, and my health insurers based on this Authorization before receipt of the cancellation.

I understand I may request a signed copy of this Authorization.