Patient support for eligible and enrolled patients prescribed Dysport
For HCPs
For Patients/Caregivers
IPSEN CARES Program Enrollment Is Quick and Easy
Eligible Patients must be enrolled to access all IPSEN CARES support offerings.
Patient and HCPs can fill out the IPSEN CARES Enrollment Form at the office. The form can either be filled out online and then submitted electronically, or it can be printed and then faxed to IPSEN CARES.
Once a completed Enrollment Form is received, an IPSEN CARES Patient Access Manager will conduct a benefits verification to review the patient’s out-of-pocket costs associated with the Ipsen medication. Additional support offerings for which the patient may be eligible will be discussed at that time.
Help With Copays?
Commercially-insured patients may be eligible* to receive copay assistance.
Key Eligibility Criteria
- Your patient currently has commercial (private) health insurance that covers Dysport
- Your patient also has no primary or secondary insurance coverage under any state or federal healthcare program
- Your patient has US residency
- Your patient has a valid prescription for Dysport
HCPs can submit claims for reimbursement by uploading required documentation via the copay website.
This offer is not valid for cash-paying patients or patients currently enrolled in Medicare, Medicaid, or any other federal or state healthcare program. Limitations apply. Void where prohibited.
*Copay Assistance Program Patient Eligibility & Terms and Conditions: Patients are not eligible for copay assistance through IPSEN CARES® if they are enrolled in any state or federally funded programs for which drug prescriptions or coverage could be paid in part or in full, including, but not limited to, Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, or TRICARE (collectively, “Government Programs”), or where prohibited by law. Patients must be United States residents (including its territories) and enrolled in IPSEN CARES® to receive copay program benefits. Patients residing in Massachusetts or Rhode Island can only receive assistance with the cost of Ipsen products but not the cost of related medical services (injection). Patients receiving assistance through another assistance program or foundation, free trial, or other similar offer or program, are not eligible for the copay assistance program during the current enrollment year.
An annual calendar year maximum copay benefit applies. Patients may remain enrolled in copay assistance as long as eligibility criteria is met.
Patients or guardians are responsible for reporting receipt of copay savings benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled through the program, as may be required. Additionally, patients or guardians may not submit any benefit provided by this program for reimbursement through a Flexible Spending Account, Health Savings Account, Health Reimbursement Account, or otherwise to a government or private payor. Ipsen reserves the right to rescind, revoke, or amend these offers without notice at any time. Ipsen and/or its copay assistance vendor are not responsible for any transactions processed under this program where Medicaid, Medicare, or Medigap payment in part or full has been applied. Claim reimbursement requests must be submitted within 180 days of treatment date. Data related to patient participation may be collected, analyzed, and shared with Ipsen for market research and other purposes related to assessing the program. Data shared with Ipsen will be de-identified, meaning it will not identify the patient. Void outside of the United States and its territories or where prohibited by law, taxed, or restricted. This program is not health insurance. No other purchase is necessary. Copay assistance cannot be sold, purchased, traded, or counterfeited. Void if reproduced.
Patient Assistance Program
Patients may be eligible to receive free drug through our Patient Assistance Program if they are experiencing financial hardship and meet financial eligibility criteria, are uninsured or functionally uninsured, are residents of the U.S., and received a valid prescription for an on-label use of Dysport as supported by information provided in the program application. Eligibility does not guarantee approval for participation in the program.
Please fill out an enrollment form if you're interested to see if your patient qualifies.
Patient Authorization
Patients/caregivers are required to sign the Dysport Patient Authorization Form every 3 years or sooner if required by state law to give the Patient Access Specialists at IPSEN CARES permission to access the patient’s personal health information in order to help with treatment. The form can be signed and submitted online, or by downloadable PDF, which must be printed, filled out, signed, and faxed.
Help With Copays?
The Dysport Copay Assistance Program for eligible*, commercially insured patients is available by enrolling in IPSEN CARES. Patients may pay as little as $0 per prescription.
*Key Eligibility Criteria
- You currently have commercial (private) health insurance that covers Dysport
- You also have no primary or secondary insurance coverage under any state or federal healthcare program
- You have US residency
- Patient has a valid prescription for Dysport
Patients can enroll for copay assistance and submit claims for reimbursement by uploading required documentation via the copay website.
This offer is not valid for cash-paying patients or patients currently enrolled in Medicare, Medicaid, or any other federal or state healthcare program. Limitations apply. Void where prohibited.
Copay Enrollment
Visit WebsiteMember Reimbursement Form
DownloadDysport Copay Assistance Brochure
Download*Copay Assistance Program Patient Eligibility & Terms and Conditions: Patients are not eligible for copay assistance through IPSEN CARES® if they are enrolled in any state or federally funded programs for which drug prescriptions or coverage could be paid in part or in full, including, but not limited to, Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, or TRICARE (collectively, “Government Programs”), or where prohibited by law. Patients must be United States residents (including its territories) and enrolled in IPSEN CARES® to receive copay program benefits. Patients residing in Massachusetts or Rhode Island can only receive assistance with the cost of Ipsen products but not the cost of related medical services (injection). Patients receiving assistance through another assistance program or foundation, free trial, or other similar offer or program, are not eligible for the copay assistance program during the current enrollment year.
An annual calendar year maximum copay benefit applies. Patients may remain enrolled in copay assistance as long as eligibility criteria is met.
Patients or guardians are responsible for reporting receipt of copay savings benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled through the program, as may be required. Additionally, patients or guardians may not submit any benefit provided by this program for reimbursement through a Flexible Spending Account, Health Savings Account, Health Reimbursement Account, or otherwise to a government or private payor. Ipsen reserves the right to rescind, revoke, or amend these offers without notice at any time. Ipsen and/or its copay assistance vendor are not responsible for any transactions processed under this program where Medicaid, Medicare, or Medigap payment in part or full has been applied. Claim reimbursement requests must be submitted within 180 days of treatment date. Data related to patient participation may be collected, analyzed, and shared with Ipsen for market research and other purposes related to assessing the program. Data shared with Ipsen will be de-identified, meaning it will not identify the patient. Void outside of the United States and its territories or where prohibited by law, taxed, or restricted. This program is not health insurance. No other purchase is necessary. Copay assistance cannot be sold, purchased, traded, or counterfeited. Void if reproduced.
Patient Assistance Program
Patients may be eligible to receive free drug through our Patient Assistance Program if they are experiencing financial hardship and meet financial eligibility criteria, are uninsured or functionally uninsured, are residents of the U.S., and received a valid prescription for an on-label use of Dysport as supported by information provided in the program application. Eligibility does not guarantee approval for participation in the program.
Please fill out an enrollment form if you're interested to see if you qualify.
Patients and Healthcare Providers can also call IPSEN CARES at (866) 435-5677
