Find your savings card below, show it at the pharmacy with your prescription and insurance card, and keep it for your refills.
Please dispense up to program maximum, which is subject to change, after Insured Patients pay the first $0. Any remaining amounts due after the use of this voucher are the responsibility of the patient.
Trifluent Pharma, LLC and/or Pharmacy Benefit Manager reserve the right to audit and review all records and documentation relating to the redemption of this coupon and the dispensing of this product.
This claim may be submitted electronically using the BIN/PCN. Submit all claims in NCPDP Standard D.0. Secondary processing should follow NCPDP standards for Co-Pay Only billing (other coverage code 8); or in some cases, using Coordination of Benefits processing, depending on your pharmacy’s software requirements. You will be reimbursed per your contracted rate directly from PBM.
By using this coupon, you and your pharmacist understand and agree to comply with these terms and conditions.
Coupon not valid for prescriptions reimbursed in whole or in part under Medicaid, Medicare (including Medicare Advantage and Part D prescription drug plans), or any other federal or state program (including state pharmaceutical assistance programs) or where prohibited, taxed, or otherwise restricted.
This coupon is not insurance. Offer may not be combined with any other rebate, coupon, free trial or similar offer. Coupon has no cash value. No cash back.
It is a violation of Federal law for a Pharmacy, Physician, or employee of Trifluent Pharma, LLC to knowingly violate this program’s business rules and may instigate an immediate claims reversal.
The selling, purchasing, trading or counterfeiting of this coupon is prohibited by law. Offer good only in the USA at participating retail pharmacies and cannot be redeemed at government-subsidized clinics.
Trifluent Pharma, LLC reserves the right to rescind, revoke or amend this offer without notice.
Restore patient’s profile to Primary PBM, if appropriate, after claim submission.
Cards are listed A–Z by product. Check the NDC against your prescription label to be sure you have the right one.
