Participating patients and pharmacists understand and agree to comply with the terms and conditions of
Prescription Co-pay Program as set forth herein.
GENERAL TERMS AND CONDITIONS: Valid only in the United States and Puerto Rico at participating
retail pharmacies. Not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by
Medicaid, Medicare, or other federal or state healthcare programs (including any state prescription drug
assistance programs). Not valid in Massachusetts or where otherwise prohibited by law. Cannot be
combined with any other rebate, coupon, free trial, or similar offer for the specified prescription. Limited to
one per person during this offering period and is not transferable. Duplicates of the coupon are invalid;
only an original coupon will be accepted. Coupon is good for 6 refills of 30-day supplies or 2 refills of 90-
day supplies. Pivotal Therapeutics and OPUS Health reserve the right to rescind, revoke, or amend the
coupon without notice. Coupon is the property of Pivotal Therapeutics and must be returned upon
request. Offer is not an insurance program and no membership fees apply.
Patient Instructions: Must be 18 or older. Present this card to your participating pharmacy, along with
your insurance card and a valid prescription for VASCAZEN®, to reduce your amount due by up to $35
after you pay the first $25 on each prescription. Card is valid for up to 6 uses. Your acceptance of this
offer must be consistent with the terms of any drug benefit provided by your health insurer, health plan, or
private third-party payor, and you agree to report acceptance of this offer to your health insurer, health
plan, or third-party payor, as may be required. You must deduct the value received under this program
from any reimbursement request submitted to your insurance plan, either directly by you or on your
behalf. The coupon is not valid for prescriptions that are eligible to be reimbursed by private insurance
plans or other health or pharmacy benefit programs that reimburse you for the entire cost of your
Pharmacist Instructions: Participation in this program must comply with all applicable laws and
contractual or other obligations as a pharmacy provider. This card must be accompanied by a valid
prescription for VASCAZEN®. For insured patients, submit the copay authorized by the patient’s primary
insurance as a secondary transaction to OPUS Health. For self-pay patients, submit the claim at U&C.
You will receive a professional fee from OPUS Health with your next remittance. Pharmacists with
questions, please call OPUSHealth at 1-800-364-4767. When redeeming the coupon, you must (i) receive
the coupon from an eligible patient, (ii) dispense the product as indicated (iii) refrain from retaining or
providing to any person or entity any portion of the amount being made available to the patient, and (iv)
otherwise comply with the terms hereof.
|VASCAZEN® Order Numbers:
||Cardinal Health: 4578803