What is the SEMGLEE® Trial Voucher Program?

The program offers your eligible patients new to SEMGLEE a free trial of five SEMGLEE pens or two SEMGLEE vials. Patients must be uninsured or insured with coverage for SEMGLEE. Limit one SEMGLEE Trial Voucher per eligible patient.

Please fill in the following information about you and your patient. This information will be used to request a SEMGLEE Trial Voucher for your eligible patients.

Please answer the highlighted question(s) in red.

Please complete the information below about your HCP office. (Information may be disclosed for state law reporting purposes.)

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Limit one voucher redemption per eligible patient. Voucher must be accompanied by a valid, signed prescription for five SEMGLEE pens or two SEMGLEE vials. Not valid for refills.

Terms and Conditions:

Patients must be new to SEMGLEE and have not previously filled a prescription for SEMGLEE. Void where prohibited by law. Product dispensed pursuant to these terms and conditions of voucher. Patients must be uninsured, have commercial insurance with coverage for SEMGLEE, or participate in any state or federally funded healthcare program, including but not limited to any state pharmaceutical assistance program, Medicare (Part D or otherwise), Medicaid, Medigap, VA or DOD, or TRICARE with coverage for SEMGLEE. This offer is not valid for commercially insured patients without coverage for SEMGLEE or patients that participate in any state or federally funded healthcare program without coverage for SEMGLEE. Neither pharmacist nor patient may submit a claim for product dispensed pursuant to this voucher to any public or private third-party payer or any federal or state health care program for reimbursement. Patient must not count free product dispensed pursuant to this voucher towards any out-of-pocket cost obligations, such as Medicare Part D True Out-of-Pocket Costs (TrOOP). Offer not valid if reproduced or submitted to any other payer. This voucher can be redeemed only by patients who are 18 years of age or older. This voucher cannot be combined with any other savings, free trial or similar offer for the specified prescription. This voucher is not intended to be used by a patient who receives a drug sample. This voucher is not transferable. This free trial is not health insurance. Offer good only in the U.S. and its territories. No purchase is necessary. Patients have no obligation to continue use of SEMGLEE. It is illegal for any person to sell, purchase or trade, or offer to sell, purchase or trade, or to counterfeit this voucher. Prescriber ID# required on prescription. McKesson retains the right to review all records and documentation relating to the filling/dispensing of product. Mylan Specialty L.P., a Viatris Company, reserves the right to rescind, revoke or amend this offer at any time. Offer valid through 12/31/2021.

NOTICE: Data related to your use of this voucher may be collected, analyzed and shared with Mylan Specialty L.P. for market research and other purposes related to assessing coupon programs. Data shared with Mylan Specialty L.P. will be aggregated and de-identified, meaning it will be combined with data related to other voucher redemptions and will not identify you.