Pharmacist Instructions for a Patient with an Eligible Third Party Payer: When you redeem this offer, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription. Submit the claim to the primary Third Party Payer first, then submit the balance due to CHANGE HEALTHCARE, as a Secondary Payer, as a copay only billing using a valid Other Coverage Code (eg, 8). For prescription fill(s) of up to a 30 day supply, eligible commercially insured patients who are “covered” will incur an out-of-pocket expense of $0. If coverage is rejected due to Prior Authorization, step-edit or NDC block, patients are still considered eligible, “not covered”, and pharmacists can submit Other Coverage Code of 03 (secondary claim). The out-of-pocket expense for “not covered” patients will be $10 per prescription fill for up to a 30 day supply.
For commercially insured patients with a deductible, please follow instructions for covered patients using a valid Other Coverage Code (eg, 8). The out-of-pocket expense for deductible patients will be $10 per prescription fill for up to a 30 day supply. Pharmacist Instructions for a Cash-Paying Patient: Cash-paying patients may receive up to $100 off each prescription fill for 30 day supply. Submit this claim to CHANGE HEALTHCARE using a valid Other Coverage Code (eg, 1). After receiving a savings of $100, patients pay remaining balance; out-of-pocket costs may vary. Reimbursement will be received from CHANGE HEALTHCARE.
For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-433-4893.
Restrictions: This offer is valid only in the United States and may not be available in all states. Program is applicable only to commercially insured patients. Cash discount cards are not commercial payers and are not eligible to be used for this program. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan (including Medicare Advantage and Parts A, B and D plans), Medigap, VA, DOD, CHAMPUS, or TRICARE or other federal or state health programs (such as medical assistance programs). If the patient is eligible for benefits under any such program, the patient cannot use this offer. By using this offer, the patient certifies that he or she will comply with any terms of his or her health insurance contract requiring notification to his or her payer of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable and has no cash value. Cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription(s). Not valid if reproduced. Void where prohibited by law. Program managed by ConnectiveRx, on behalf of Neos Therapeutics. The parties reserve the right to rescind, revoke, amend or terminate this offer without written notice at any time. Patient age or insurance restrictions may apply.