ACTIVATE SAVINGS CARD
Already have a ULORIC Savings Card?
Register to enroll in GoutSmart and activate your existing ULORIC Savings Card.
Contact Information
Please note that all information is required unless noted as optional.
First Name:
Last Name:
E-mail:
Retype E-mail:
5-digit ZIP Code:
Please note that this program is open to U.S. residents only.
SAVINGS CARD ACTIVATION
Please enter the 12-digit ID# displayed on the front of your ULORIC Savings Card.
Please tell us a little more about yourself so we can customize your resources
When were you born?
Month
January
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Year
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OPTIONAL: Would you also like to receive information about gout and ULORIC by mail in the future?
If so, please provide your postal address here. (This is optional)
Street Address - Line 1:
Street Address - Line 2:
City:
State:
(Select)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
 
 
Terms and Agreement
By clicking the “Activate” button below, I certify that I am not covered by:
Any federal or state healthcare program such as Medicare, Medicaid, Veterans Administration, TriCARE, etc., including state medical or pharmaceutical assistance programs;
The Medicare Prescription Drug Program (Part D), or I am not currently covered in the coverage gap;
Insurance that is paying the entire cost of the prescription;
An insurer or other Third Party Payor in Massachusetts.
Your Privacy
By clicking the “Activate” button below, I understand that I am giving Takeda Pharmaceuticals U.S.A., Inc., its affiliates and business partners, permission to use my personal information to provide me with information and offers related to gout and related treatment options. I understand I may revoke my permission at any time. To learn how Takeda will use and protect your personal information, click here to view our Privacy Policy .