Adcirca® (Tadalafil) Copayment Assistance Program

Patient Registration

* Are you, or the patient currently enrolled in Medicare, Medicaid, TriCare, Veterans Administration, State Pharmaceutical Assistance programs, or other Federal or State programs? This program is not valid for prescriptions reimbursed under Medicare, Medicaid, VA, DoD, (TRICARE), Indian Health Services, or other similar federal or state program.

* Is the patient enrolling in the program 18 years of age or older?

* Please indicate the state in which the patient resides

* First Name

* Last Name

* Gender

* Date of Birth (mm/dd/yyyy)

* Street Address

Address 2

* City

* Zip

* Phone Number (XXX-XXX-XXXX)

* Email Address (test@gmail.com)

* Please indicate the Specialty Pharmacy you wish to fill your prescription at

* By enrolling you agree that you may receive information describing the various no-cost support programs offered by United Therapeutics Corporation or important updated information related to the Adcirca Copayment Assistance Program. You may cancel future communications and it will not affect your eligibility for the Adcirca Copayment Assistance Program. To withdraw your consent to receive these types of communications, please call an ASSIST associate at 877-864-8437.

Please register and activate a Copayment Identification Number which can be used for your prescription of Adcirca (tadalafil) tablets . BY REGISTERING IN THIS PROGRAM, YOU UNDERSTAND AND AGREE TO COMPLY WITH THE ELIGIBILITY REQUIREMENTS AND TERMS OF USE SET FORTH BELOW.

Eligibility Requirements

  • The Program is valid only for patients with commercial (also known as private) insurance who are taking the medication for an FDA approved indication.
  • Patients using Medicare, Medicaid, or any other state or federal government program to pay for their medications are not eligible. Patients who start utilizing government coverage during the term of the Program will no longer be eligible.
  • Eligible patients must be a resident of the US or Puerto Rico
  • Void where prohibited taxed or restricted by law,
  • You must be 18 years or older to use this Program.

Additional Terms and Conditions

  • This Program is only valid for cost of the drug Adcirca and not applicable to any related supplies or other medical expenses associated with administering the product.
  • This Program is not conditioned on any past, present or future purchase, including refills.
  • The patient confirms that this Program is consistent with patient's insurance. The patient is responsible for reporting the receipt of all Program benefits as required by the insurance company.
  • This Program is not insurance and is not intended to substitute for insurance.
  • Limit 1 (one) Copayment Identification Number per patient.
  • This ID number is non-transferable and has no value
  • 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.
  • United Therapeutics reserves the right to modify or terminate this program at any time without notice.
  • By enrolling in the Program, you agree that your personal information may be used by United Therapeutics and its affiliates to send you information about United Therapeutics products, programs, support and services related to your condition and contact you in connection with your participation in the Program and as provided in our Privacy Policy. United Therapeutics respects the privacy of your personal information and you may unsubscribe from our programs at any time by calling 1-877-864-8437.