AVOID THE STOP
LEARN MORE ABOUT BPH
AND GO OF BPH.
BPH = benign prostatic hyperplasia.
1. This offer is valid only for patients with commercial prescription drug insurance. 2. Depending on your insurance coverage, most eligible patients pay no more than $15 per 30 capsules or no more than $20 per 90 capsules for each prescription of RAPAFLO® filled. Check with your pharmacist for your co-pay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. 3. This card is not valid for prescriptions submitted for reimbursement by Medicare, Medicaid, Tricare, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. 4. This card is good for use with a RAPAFLO® prescription at the time the prescription is filled by the pharmacist and dispensed to the patient. 5. Each card is valid for up to 16 prescription fills of 30 capsules each OR up to 5 prescription fills of 90 capsules each; offer applies only to prescriptions filled before the program expires on 12/31/18. 6. Allergan reserves the right to rescind, revoke, or amend this offer without notice. 7. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies. 8. Void if prohibited by law, taxed, or restricted. 9. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 10. This card has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. 11. This offer is not health insurance. 12. This card expires December 31, 2018. 13. By redeeming this card, you acknowledge that you are an eligible insured patient and that you understand and agree to comply with the terms and conditions of this offer.
Pharmacist instructions for a patient with an Eligible Third Party: Submit the claim to the Primary Third Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 8).
Patients are responsible for up to the first $15 or $20 (for 30 or 90 capsules, respectively). Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the help desk at 1-800-422-5604.
Program expires December 31, 2018. Program managed by ConnectiveRx on behalf of Allergan. The parties reserve the right to rescind, revoke, or amend this offer without notice at any time. Not valid if reproduced. This offer is valid in the United States. Void where prohibited by law.
For questions regarding your eligibility please call 1-855-276-2952.