Orenitram® (Treprostinil) Co-Pay Assistance Program

Patient Registration

* Are you, or the patient currently enrolled in Medicare, Medicare Part D, 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

* Does the patient enrolling in the co-pay program have a valid Prior Authorization (PA) on file with their insurer for the prescribed United Therapeutics medication? If you are unsure if a Prior Authorization is on file, please contact your insurance plan to verify.

* First Name

* Last Name

* Gender

* Date of Birth (mm/dd/yyyy)

* Street Address

Address 2

* City

* Zip Code (numbers only)

* Phone Number (XXXXXXXXXX)

* Email Address (test@gmail.com)

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

* By enrolling, I agree to have my personal information used to provide me with information and resources regarding products, programs, and services related to my condition, including treatment information. Information sent by United Therapeutics does not take the place of talking to your healthcare provider about your treatment or condition. United Therapeutics, or third parties working on its behalf, will not sell your information or use it for unrelated purposes. If in the future you no longer want to receive these materials or participate in these programs, please call 877-864-8437.

Please register and activate a Co-Pay Identification Number which can be used for your prescription of Orenitram (treprostinil) extended release 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 Orenitram 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) Co-Pay 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.