LIFYORLI Free Trial Offer Voucher

The LIFYORLI Free Trial Offer Voucher provides one 28-day trial of LIFYORLI at no cost for eligible new patients regardless of insurance coverage status.*

To be eligible, patients must:

Be prescribed LIFYORLI by a licensed US healthcare provider
Have a valid 28-day prescription for an FDA-approved use of LIFYORLI
Have not previously filled a prescription for LIFYORLI
Be 18 years of age or older
Live in the US or a US territory

This voucher can only be accepted at participating pharmacies within the authorized distribution pharmacy network. To learn more or authorize your pharmacy, reach out to your Corcept Account Manager or call 1-312-449-1354.

If you have any questions, call LIFYORLI Support™ at 1-85-LIFYORLI (1-855-439-6754), Monday-Friday, 8 AM-8 PM ET, or visit LIFYORLIhcp.com/support.

*See full Terms and Conditions at LIFYORLIfreetrialvoucher.com/Terms-and-Conditions.

Corcept Therapeutics, Inc. is committed to protecting each patient's privacy and personal data. If the patient has questions about how we use and protect their personal data or about their potential rights, please direct them to see the Corcept Therapeutics, Inc. Privacy Notice at https://corcept.com/privacy-notice.

By submitting this information, you certify that you have obtained the patient's authorization to provide their personal information listed below for participation within this program. You agree that you have and will retain the patient's HIPAA authorization. You agree that you will make the patient's authorization available to Corcept and its affiliates upon request should there be a need to confirm a patient's authorization to participate in this program.

Patient Information

Patient First Name

Patient Last Name

Address Line 1

Address Line 2 (optional)

City

State

ZIP

Date of Birth

Month

Day

Year

Phone Number

Pharmacy and Prescriber Information

Prescriber First Name

Prescriber Last Name

Pharmacy NCPDP ID (optional)

Prescriber DEA Number (optional)

LIFYORLI Free Trial Offer Voucher Full Terms & Conditions

By redeeming this voucher, the patient, prescriber and pharmacist acknowledge and agree to comply with the program eligibility criteria and terms and conditions described below.

The LIFYORLI Free Trial Offer Voucher is solely intended to allow eligible new patients a fair trial of LIFYORLI™ (relacorilant) to determine with their prescriber whether LIFYORLI is right for them.
The LIFYORLI Free Trial Offer Voucher may be redeemed for one 28-day trial of LIFYORLI for its FDA-approved indication. Only patients new to LIFYORLI may use this voucher. Patients who have previously used or are currently using LIFYORLI are not eligible for this voucher offer.
Patients may be offered the LIFYORLI Free Trial Offer Voucher exclusively by their healthcare provider.
This offer is valid for eligible patients regardless of insurance coverage.
This voucher can only be accepted at participating pharmacies within the authorized distribution pharmacy network.
This voucher is not health insurance.
No claim for payment can be made to ANY third-party payer for medication dispensed pursuant to this offer.
Participating patients, pharmacists, and prescribers agree not to seek reimbursement from any insurer, health plan, or third party for any part of the benefit received through this voucher and agree that any medication received through this voucher shall not be sold, traded, bartered, or otherwise transferred.
Participating patients cannot use the value of the free medicine provided through the LIFYORLI Free Trial Offer to count toward any insurer or health plan's out-of-pocket spending limits, including, but not limited to, Medicare Part D true out-of-pocket costs (TrOOP) for prescription drugs.
This voucher may not be combined with any other coupon, free trial, discount, prescription savings card, or similar offer for LIFYORLI.
This voucher is non-transferable, limited to one per person, and void where prohibited by law, taxed, or restricted. Not valid if reproduced.
Participation in LIFYORLI Free Trial Offer Voucher is free. No purchase necessary. This offer is not conditioned on any past, present, or future purchase, including refills.
Corcept Therapeutics reserves the right to rescind, revoke, or amend this offer, eligibility, and terms of use at any time without notice. Other limitations may apply.

Pharmacy Instructions:

Pharmacist Instructions for using voucher for an eligible new patient: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any third party payer in coordination with this offer.

Process a PRIMARY claim to BIN: 024284 using this voucher's details. Do not submit a Coordination of Benefits (COB) claim to any third-party payer with this voucher offer.
Valid Other Coverage Code required (e.g., 01). For any questions regarding processing, please call the Pharmacy Help Desk at (312)-449-1354. Program managed by Apollo Care on behalf of Corcept Therapeutics.
Voucher offer valid only for participating pharmacies.
For general questions, patients and providers should call 1-85-LIFYORLI (1-855-439-6754).

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LIFYORLI Free Trial Offer Voucher Preview

For enrollment questions, call LIFYORLI Support™ at 1-85-LIFYORLI (1-855-439-6754), Monday-Friday, 8 AM-8 PM ET, or visit LIFYORLIhcp.com/support.

If you are a pharmacy receiving rejection codes 51/MR or 40 when attempting to process a claim, please contact your Corcept Oncology Account Manager (OAM). Your pharmacy may not be enrolled in this program.

You may also call 1-312-449-1354.