PATIENT
ELIGIBILITY

*Required fields.

Do you confirm you are a US resident or a resident of a US Territory?*

Yes

Please make a selection.

Do you confirm you are 18 years of age or older?*

Yes

Please make a selection.

Patient Date of Birth*

Patients who are not 18 years of age or older are not eligible to participate in the program.

Please provide the information below.

Lexicon Pharmaceuticals respects your privacy and is committed to maintaining and protecting the confidentiality of the information you share with us. By activating, you agree to let Lexicon Pharmaceuticals, its affiliates or service providers, periodically send you patient education and product support services information, as well as other materials related to Lexicon Pharmaceuticals products and services. You will be able to opt out at any time.

Patient First Name*

Please enter First Name.

Patient Middle Initial

Patient Last Name*

Please enter Last Name.

Patient Gender*

Male

Female

Other

Please select Gender.

Patient Home Address Line 1*

Please enter Address Line 1.

Patient Home Address Line 2

City*

Please enter City.

State*

Please enter State.

ZIP Code*

Please enter ZIP Code.

Patient Email Address*

Please enter Email Address.

Patient Home Phone*

Please enter Home Phone.

Patient Cell Phone*

Please enter Cell Phone.

SMS ALERTS

Opt-in to receive your digital INPEFA Together™ Savings Program card and refill reminders via text.
Messages & data rates may apply. Message frequency varies. Text HELP for help. Text STOP to opt out. Terms & Conditions and Privacy Policy apply.
For Privacy Policy https://www.lexpharma.com/privacy-policy.
For SMS Terms https://smsterms.copaysavingsprogram.com/inpefa.

Yes, opt me in.

No, I do not want to receive SMS alerts.

Text VOUCHER to 43496 to enroll and activate an INPEFA Together^™ Savings Card with your phone. Or, continue with your selection below and enroll online.

DO YOU WANT TO DOWNLOAD OR ACTIVATE AN INPEFA TOGETHER^™ SAVINGS CARD?

CARD
DETAILS

PATIENT
ELIGIBILITY

SMS ALERTS

Text VOUCHER to 43496 to enroll and activate an INPEFA Together™ Savings Card with your phone. Or, continue with your selection below and enroll online.

DO YOU WANT TO DOWNLOAD OR ACTIVATE AN INPEFA TOGETHER™ SAVINGS CARD?

CARD DETAILS

PATIENT ELIGIBILITY

SMS ALERTS

Text VOUCHER to 43496 to enroll and activate an INPEFA Together^™ Savings Card with your phone. Or, continue with your selection below and enroll online.

DO YOU WANT TO DOWNLOAD OR ACTIVATE AN INPEFA TOGETHER^™ SAVINGS CARD?

CARD
DETAILS

PATIENT
ELIGIBILITY