Dear Patient: Present the attached coupon card to your pharmacist along with your valid prescription for instant savings on eligible prescriptions.
Please see Redemption Instructions below for details. Restrictions may apply.
Keep this coupon card for future refills.
Expires December 31, 2017.
*For cash-paying patients or insured patients when these brands are not covered by primary insurance, patients may still use this savings card but may have an outstanding balance.
Eligible patients whose primary insurance covers their prescription Ecoza™, Neosalus®, or Recedo™ will pay a minimum of $25 and the card pays up to the NDC benefit maximum. Cash-paying patients or insured not covered patients may pay up to $150 and the card pays up to the NDC benefit maximum. Offer valid for up to 24 uses. A valid Prescriber ID# is required on the prescription.
Patient Instructions: In order to redeem this offer you must have a valid prescription for Ecoza™, Neosalus®, Recedo™. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the Exeltis Dermatology Savings offer should call
Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.
Restrictions: This offer is valid in the United States. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, Tricare or other federal or state health programs (such as medical assistance programs). If the patient is eligible for drug 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 payor of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. Program expires 12/31/2017. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. Program managed by ConnectiveRx on behalf of Exeltis USA Dermatology. The parties reserve the right to rescind, revoke or amend this offer without notice at any time.
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, (e.g. 8). The patient is responsible for the first $25 and the card pays up to the NDC benefit maximum. Reimbursement will be received from CHANGE HEALTHCARE.
Pharmacist instructions for a cash-paying patient
- Submit this claim to CHANGE HEALTHCARE. A valid Other Coverage Code (e.g. 1) is required. This card pays up to the NDC benefit maximum and the patient will be responsible for the remaining balance. Reimbursement will be received from CHANGE HEALTHCARE.
- Valid Other Coverage Code required. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604.