Eligibility questions

All fields are required.

Please answer the questions below to see if you are eligible for an AVSOLA® Co-Pay Card.

I am 18 years of age or older and live in one of the 50 United States or a US territory.
What type of insurance do you use to pay for your AVSOLA® prescription at the doctor's office? (please select one option)

Commercial insurance (e.g., self-purchased or through an employer)?

Government-provided (e.g., Medicare Part D, Medicaid)?

I don't have insurance

I don't know

Are you eligible for Medicare but receive prescription drug coverage from a former employer, union or welfare plan?

By checking this box, I agree that I read, understand and accept the Terms and Conditions of the AVSOLA® Co-Pay Program.

Health insurance you or a family member purchased and/or receive through an employer, healthcare exchange, or a commercial plan through the Federal Employee Health Benefits (FEHB) program.
Includes Medicare Part D, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs.