†Terms and Conditions
Maximum benefit of $100 per two-pack of Auvi‑Q® (epinephrine injection, USP), up to a maximum of three two-packs per prescription. This offer can be used an unlimited number of times until 12/31/2015. Prescriber ID# required on prescription.
If prescription is covered by insurance, you may need to notify the insurance carrier of redemption of this copay card. This offer is not valid for prescriptions covered by or submitted for reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including any state medical pharmaceutical assistance program. This program is not valid where prohibited by law. By redeeming this coupon, you are certifying that (1) you are not a beneficiary of any government funded programs as noted above; (2) should you begin receiving prescription benefits from any government funded program, you will withdraw from this savings program; and (3) you acknowledge and understand that adherence to the terms and conditions of this offer is necessary to ensure compliance with laws pertaining to Federal Healthcare Programs. In order to redeem this card you must have a valid prescription for Auvi‑Q. Follow the dosage instructions given by the doctor. This card may not be redeemed for cash. Only one card per patient. For questions regarding your eligibility or benefits or if you wish to discontinue your participation, please call 1-855-226-3941.
When you process this card, you are certifying that you have read, understood, and are in compliance with the terms and conditions pertaining to this program. You are further certifying that you have not submitted and will not submit a claim for reimbursement under Medicaid, Medicare, VA, DOD, TRICARE, or similar federal or state programs including any state medical pharmaceutical assistance program for this prescription.
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 Therapy First Plus as a Secondary Payer coordination of benefits with patient responsibility amount and a valid Other Coverage Code (e.g., 8). The Patient pay amount submitted will be reduced by up to $100 per two-pack. Reimbursement will be received from Therapy First Plus.
Pharmacist Instructions for a Cash-Paying Patient:
Submit the claim to Therapy First Plus. A valid Other Coverage Code (e.g., 1) is required. The Patient pay amount submitted will be reduced by up to $100 per two-pack. Reimbursement will be received from Therapy First Plus.
Valid Other Coverage Code required. For any questions regarding Therapy First Plus online processing, please call the Help Desk at 1‑800‑422‑5604.
The card is not transferable and the amount of the rebate cannot exceed the patient's out-of-pocket expenses. Program expires 12/31/2015. Program managed by PSKW, LLC on behalf of sanofi-aventis U.S. LLC. Product dispensed pursuant to program rules and federal and state laws. The parties reserve the right to amend or end this program at any time without notice.