IMPORTANT SAFETY INFORMATION
Do not take AZILECT® (rasagiline tablets) if you are taking meperidine as it could result in a serious reaction such as coma or death. Also, do not take AZILECT with tramadol, methadone, propoxyphene, dextromethorphan, St. John’s wort, or cyclobenzaprine. You also should not take AZILECT with other monoamine oxidase inhibitors (MAOIs), as it could result in an unsafe rise in blood pressure. Read More Important Safety Information

AZILECT Co-pay Program

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Terms and Conditions

Printing a new co-pay card

Eligibility restrictions and terms and conditions apply. See below for details.

Eligibility Information

To register your AZILECT co-pay card, we will need to ask you for personal information. It is important to provide accurate information. This information may be used by Opus Health ("Opus") during the time that it acts as the paid administrator in connection with the AZILECT Coupon Program for the purposes of assessing eligibility under the Terms and Conditions of co-pay card use, activating the card (for eligible patients), and fraud verification.

Teva Neuroscience, Inc. understands that your privacy is important. Please note that by providing your name, address, or other information, you are giving Teva and companies working with us permission to communicate with you via traditional mail, email, telephone, or text about AZILECT. We will not sell or transfer your name, address, or other personally identifiable information about you to any party for its own marketing use.

*Required Fields

I agree to the above statement.*


Are you 18 years of age or older?*


Are you a resident of the United States or the Commonwealth of Puerto Rico?*


Are your prescriptions paid for in part or in full by any state or federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, TRICARE®, CHAMPUS, or the Puerto Rico Government Health insurance plan, or reimbursed in full (including co-pay) by any third-party payer?*


If you begin receiving prescription benefits from any state, federal, or other government-funded program at any time, you will no longer be eligible to participate in this program. Do you acknowledge agreement with this statement?*


Personal Information

Please complete the following form to sign up to receive a co-pay card for AZILECT.

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Gender*
Male Female
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Preferred Method of Communication

How long have you had Parkinson's Disease?

How long have you been taking AZILECT?

Program Rules - Patient Eligibility and Terms and Conditions:

Valid only for qualified patients with a valid prescription for AZILECT® (rasagiline tablets). No substitutions are permitted. This card is valid only for those with private insurance or for cash-paying patients. This card is not valid for prescriptions paid for in part or in full by any state or federally funded program, including but not limited to Medicare or Medicaid, Medigap, VA, DOD, Tricare®, or the Puerto Rico Government Health Insurance Plan, or by private health insurance plans or programs that reimburse patients for the entire costs of their prescription drugs. This card is not valid for patients who are Medicare eligible and are enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., patients who are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). Patient discount with this card is valid to reduce the co-pay to $5, with a maximum benefit of $110 per month. For example, if the total co-pay is $115 or less, the patient will pay no more than $5 per month. If the co-pay is more than $115, the patient’s co-pay will be reduced by a maximum amount of $110 per month. Offer expires December 31, 2015.

Your acceptance of this offer must be consistent with the terms of any drug benefit provided by a health insurer, health plan, or other third-party payer, and you agree to report acceptance of this offer to your health insurer, health plan, or third-party payer as may be required. Offer limited to one card per person and may not be used with any other discount, coupon, or offer. Offer is not transferable. It is illegal to sell, purchase, trade, or counterfeit this card. This card is not health insurance. This card is the property of Teva Neuroscience, Inc., and must be returned upon request. Offer is valid only in the United States or the Commonwealth of Puerto Rico at participating pharmacies. Void in any state where prohibited by law, taxed, or restricted. Teva Neuroscience, Inc., reserves the right to change, rescind, revoke, or discontinue this offer at any time without notice. By participating in this program, you, the patient, certify that (a) you have read the above terms; (b) you are not reimbursed, nor will you submit a claim for reimbursement, nor will you seek to have any portion of this prescription counted toward your out-of-pocket costs (e.g., TROOP) under any federal, state, or private programs for this or other prescriptions for AZILECT to which this offer will apply; and (c) you will otherwise comply with the terms above.

I have read and agree with these Terms and Conditions.*

I understand that the personal information that I provide will be kept  confidential and will not be shared with third-party processing agents  other than Teva Neuroscience, Inc., and its designated agents.*

I agree that the personal information provided above may be used by  Teva Neuroscience, its affiliates, and their business partners to provide me with information about Parkinson's disease, related conditions, and products and to develop products and services concerning Parkinson's disease that may include market research. I understand that I can  request my name and other personal information be removed from future contact at any time by visiting AZILECT.com/unsubscribe.




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AZI-41015

INDICATION
AZILECT® (rasagiline tablets) is indicated for the treatment of Parkinson’s disease (PD).

IMPORTANT SAFETY INFORMATION

  • Do not take AZILECT if you are taking meperidine as it could result in a serious reaction such as coma or death. Also, do not take AZILECT with tramadol, methadone, propoxyphene, dextromethorphan, St. John’s wort, or cyclobenzaprine. You also should not take AZILECT with other monoamine oxidase inhibitors (MAOIs), as it could result in an unsafe rise in blood pressure
  • Increases in blood pressure may occur during treatment with AZILECT. Inform your physician if you have a history of high blood pressure. Possible symptoms of an unsafe rise in blood pressure include severe headache, blurred vision, difficulty thinking, seizure, chest pain, and nausea/vomiting. It is important that if you experience these symptoms that you speak with your doctor or seek medical attention. When AZILECT is taken at recommended doses, restriction of foods and beverages containing a substance called tyramine is ordinarily not required. However, it is recommended that you avoid foods containing high amounts of tyramine such as aged cheeses as some patients may have an increased sensitivity that could lead to an unsafe rise in blood pressure as described above
  • Inform your physician if you are taking, or planning to take, any prescription or over-the-counter drugs, especially antidepressants and ciprofloxacin. The combination of MAO-B inhibitors such as AZILECT and antidepressants has resulted in a serious and sometimes fatal condition called serotonin syndrome
  • If you experience episodes of falling asleep or drowsiness during activities of daily living, do not drive and exercise caution until you contact your physician
  • If you have moderate to severe liver disease, you should not take AZILECT. You should not exceed a dose of 0.5 mg per day of AZILECT if you have mild liver disease or are taking ciprofloxacin. Patients should not exceed a dose of 1 mg per day of AZILECT because of the risk of increased blood pressure
  • All PD patients should be monitored for a change in blood pressure, uncontrolled movements (dyskinesia), hallucinations, impulse control, confusion, and melanoma (skin cancer). A possible rise in body temperature may occur upon stopping AZILECT
  • The most common side effects seen with AZILECT alone are flu syndrome, joint pain, depression, and indigestion; when taken with a dopamine agonist are swelling of the legs, fall, joint pain, cough, and inability to sleep; and when taken with levodopa are uncontrolled movements (dyskinesia), accidental injury, weight loss, low blood pressure when standing, vomiting, anorexia, joint pain, abdominal pain, nausea, constipation, dry mouth, rash, abnormal dreams, fall, and swelling of tendons
  • You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088