SAVING IS SIMPLE
WITH THE ADHANSIA XR SAVINGS CARD
Present this card to the pharmacist with your prescription
With the Adhansia XR Savings Card, you could pay as little as $15* for each prescription of Adhansia XR. Use the savings card below when you fill your prescription. Present this savings card to your pharmacist along with your insurance card when you are at the pharmacy. Please keep this card in a safe place for future use.
*Maximum limits apply; your out-of-pocket expenses may vary. You are responsible for the first $15 and any amount that exceeds the total Adhansia XR Patient Savings offer.
Print, download, or email your savings card
Download or email your savings card
Important Safety Information
Please see Additional Important Safety Information, Full Prescribing Information and Medication Guide on www.AdhansiaXR.com.
FOR THE PHARMACIST
Follow these 3 easy steps to process the savings card.
- Submit a Coordination of Benefits (COB) claim using the patient's prescription insurance for the primary claim.
- If rejected due to Managed Care Restriction (e.g., Not Covered or NDC Block), continue processing COB claim using valid Other Coverage Code (OCC) of 03 or 08.
- When approved, submit a secondary claim to DST (formerly Argus), using BIN: 600428/PCN: 06780000.
TERMS & CONDITIONS
You must present this card to the pharmacist along with your prescription for
TO THE PHARMACIST:
Savings Card can only be used when accompanied by a valid prescription for
- You have dispensed the covered drug to an eligible patient in accordance with the terms of the card and accompanying prescription
- Other than TrialCard, you have not submitted and will not submit a claim for reimbursement to any Third Party Payor that prohibits use of the card, including Medicare, Medicaid, any similar federal or state healthcare program, or any patient assistance programs; and
- Your participation in this program is consistent with all applicable laws and with all of your contractual or other obligations
This card is valid only for patients with commercial (private or non-governmental) insurance. It is not valid for patients (i) who are government beneficiaries or whose prescription drugs are eligible to be reimbursed, in whole or in part, by any Federal Health Care Program, as that term is defined at 42 U.S.C. §1320a-7b(f), including Medicaid, Medicare, a Medicare Part D or Medicare Advantage plan, TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan, or any other state or federal healthcare program; (ii) who are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees; or (iii) who reside in a state where the card is prohibited.
Terms and Conditions
You must meet eligibility requirements. This card is only available with a valid prescription. The card is not valid for medications you received for free or that are eligible to be reimbursed by private insurance plans or any other healthcare pharmaceutical assistance programs that reimburse you for the entire cost of your medications. You agree not to seek reimbursement for all or any part of the benefit received through this offer. You agree to report your use of this card to any third party that reimburses you or pays for any part of the prescription price. You additionally agree that you will not submit any portion of the product dispensed pursuant to this card to a federal or state healthcare program for purposes of counting it toward your out-of-pocket expenses. This card has no cash value and is not valid with any other program, discount, or incentive involving the covered medication. Use of this card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices, and hospitals are obligated to inform third-party payers about the use of the card as provided for under the applicable insurance or as otherwise required by contract or law. This card may not be sold, purchased, traded, or offered for sale, purchase, or trade. This card is limited to one per person during the offering period and is not transferable. This offer is not contingent upon any past, present, or future purchases of the covered medication or any other product, and this offer may be rescinded, revoked, or amended without notice. No reproductions. This card is not health insurance or a benefit plan. This card is void where prohibited or where restricted beyond the terms herein. Maximum benefits apply. For questions about this card, call
Adlon Therapeutics L.P. reserves the right to rescind, revoke, or amend this offer without notice at any time.
© 2021 Adlon Therapeutics L.P. All Rights Reserved. Intended for residents of the United States only. MR-06661 V2