YCANTH Copay Assistance Program

Welcome to the YCANTH™ Copay Assistance Program

With YCANTH, qualified patients who are commercially insured may pay as little as $25 per applicator.

To initiate this offer, complete the form below to confirm the patient meets eligibility and certain terms and conditions for the YCANTH Copay Assistance Program*.

*Terms, conditions, and limitations apply. Please see below for the Program's eligibility requirements and terms and conditions.

Please enter the name of the patient who will use this coupon.

Please enter the date of birth of the patient who will use this coupon.

Please enter the address of the patient who will use this coupon.

Please enter an email address for the patient/caregiver.

Please enter a mobile number for the patient/caregiver.

The patient has been diagnosed by their healthcare provider with Molluscum Contagiosum (diagnosis code: B08.1).

Agree
Disagree

The patient enrolling in the YCANTH Copay Assistance Program is a resident of the United States.

Agree
Disagree

The patient enrolling in the YCANTH Copay Assistance Program does not have coverage, in whole or in part, by Medicaid, Medicare, VA, DOD, TRICARE (TRICARE® is a registered trademark of the Department of Defense (DOD), DHA.), or other federal or state programs including any state pharmaceutical assistance programs.

Agree
Disagree

The patient enrolling in the YCANTH Copay Assistance Program is at least two (2) years of age or older.

Agree
Disagree

I am the pharmacist or someone assisting the patient completing this form.

ELIGIBILITY CRITERIA/TERMS AND CONDITIONS:

Patients who are eligible to participate in the YCANTH Copay Assistance Program must agree to the following terms and conditions:

Patients must present a valid prescription for YCANTH to a participating retail pharmacy to receive a cost reduction on their out-of-pocket expense.
Patients understand that the YCANTH Copay Assistance Program has an annual maximum benefit of $2,605 or 4 treatments for YCANTH, whichever occurs first.
Patients must be diagnosed by their healthcare provider with Molluscum Contagiosum (diagnosis code: B08.1)
The YCANTH Copay Assistance Program is solely for patients' charges incurred in the use of YCANTH (cantharidin) topical solution and does not include any other related charges.
Patients using YCANTH must be at least two (2) years of age or older and must reside in the United States (including Puerto Rico, Guam, and the U.S. Virgin Islands).
For all qualified patients, Verrica Pharmaceuticals is responsible for all YCANTH product costs under the Program amount and excluding the copay requirement. The Patient’s insurance provider can provide the most accurate explanation of all charges.
Patient will bear financial responsibility for all costs not covered by commercial insurance exceeding maximum benefit for YCANTH. THIS IS NOT INSURANCE.
Patients with insurance, in whole or in part, from Medicaid, Medicare, VA, DOD, TRICARE (TRICARE® is a registered trademark of the Department of Defense (DOD), DHA.), or other federal or state programs including any state pharmaceutical assistance programs, are not eligible to participate in the YCANTH Copay Assistance Program.

The YCANTH Copay Assistance Program card is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer not already associated with this offer.
This Program is not valid where prohibited by law, taxed, or restricted.
Verrica Pharmaceuticals reserves the right to rescind, revoke, terminate, or amend this offer, eligibility, and terms of use at any time without notice.
Additional terms and conditions may apply.
Approval of enrollment in the Program is not guaranteed.

De-identified patient data related to redemption of the YCANTH Copay Assistance Program may be collected, analyzed, and shared with Verrica Pharmaceuticals, for market research and other purposes related to assessing patient savings programs. The patient understands they are consenting to allow Verrica Pharmaceuticals and its contracted vendor InfinityRx to store all collected personal and medical information for the administration of this program. For questions call: 888-927-3499. The healthcare information contained herein is not intended to replace discussion with a healthcare provider. All decisions regarding patient care must be made with a healthcare provider, considering the unique characteristics of the patient.