RxBIN: 610524 RxPCN: Loyalty RxGRP: 40007172 ISSUER: (80840) ID: 461721573

How the Co-Pay Card works:

  • This Co-Pay Card may be used 1 time prior to the program termination date deemed by Vernalis and provides a benefit either based on the number of ounces dispensed or the amount of your out-of-pocket cost over $10, whichever is less. Benefit is limited to a maximum amount.
  • Not all patients are eligible to use the Co-Pay Card. Please see Terms and Conditions for important eligibility restrictions.
  • If you have any questions, call 1-800-657-7613, 8 am to 8 pm EST, Monday to Friday, excluding holidays.

Prescriber:

To initiate a Co-Pay Card for an appropriate patient to use you should:

  • Write a prescription for TUZISTRA XR (codeine polistirex and chlorpheniramine polistirex) extended-release oral suspension, CIII. No substitutions are permitted.
  • Give the valid signed prescription and the Co-Pay Card to the patient.
  • Eligible patients may take or send the Co-Pay Card and the signed prescription to any participating eligible retail pharmacy to receive savings on their out-of-pocket cost (savings will vary depending on their out-of-pocket cost).
  • Not all patients are eligible to use the Co-Pay Card. Please see Terms and Conditions below. Maximum of 1 benefit per card, 6 per patient.

Pharmacist:

  • Co-Pay Card is valid only when accompanied by a prescription for TUZISTRA XR. The Co-Pay Card benefit is either based on the number of ounces dispensed or the patient's actual out-of-pocket cost over $10, whichever is less. Benefit is limited to a maximum amount. For details call 1-800-657-7613, 8 AM to 8 PM ET, Monday to Friday, excluding holidays.
  • Patient is not eligible if prescriptions are paid in part or full by any state or federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD or TriCare, or where prohibited by law.
  • You are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state or other governmental programs for this prescription.
  • Submit transaction to McKesson Corporation using BIN #610524
  • If primary commercial prescription insurance exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
  • Acceptance of this card and your submission of claims for the TUZISTRA XR program are subject to the LoyaltyScript®  program Terms and Conditions posted at www.mckesson.com/mprstnc

Terms and Conditions:

  • You must be 18 years of age or older to redeem the Co-Pay Card.
  • Patient is responsible for the first $10 of their out-of-pocket cost.
  • The Co-Pay Card is valid for up to $150 of your out-of-pocket cost over $10 on qualifying prescriptions for TUZISTRA XR. Co-Pay Card is valid for one use. No other purchase is necessary. Maximum benefit of up to $150 is based on the number of ounces dispensed.
  • The Co-Pay Card is not transferable. No substitutions are permitted. The offer cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer.
  • The Co-Pay Card is not insurance.
  • Patient is not eligible if prescriptions are paid in part or full by any state or federally funded programs, including but not limited to Medicare or Medicaid, Medigap, VA, DOD or TriCare, or where prohibited by law.
  • The Co-Pay Card can be used only by eligible residents of the United States at participating eligible retail pharmacies in the United States.
  • It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the Co-Pay Card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
  • Vernalis Therapeutics, Inc. reserves the right to terminate, rescind, revoke, or amend the offer at any time without notice.