Pay Only $15.00*
for ZOVIRAX
on Co-Pays up to $50.00
Claims Processor RESTAT
BIN # 600471 Group # X 4150 Rx PCN# 7777
Cardholder ID# 1532580
*Attention Patient: If your co-pay or pharmacy bill exceeds $15.00, present this certificate to the pharmacist for an instant rebate of “up to” a maximum of $35.00 for each product. If your total out of pocket pharmacy bill exceeds $50.00 for any single product, you will be responsible for the additional balance. Not valid with any other offer.
Remember to restore patient profile to Primary PBM after claim submission.
Expiration Date: June 1, 2012
To Ensure Reimbursement, you will need:
- BIN #, Group #, Cardholder ID #, and Rx PCN # (use numbers on reverse side)
- Standard prescription information
- Person code: Enter 001.
Remember to restore patient profile to Primary PBM after claim submission.
Call 1-866-450-3277 with processing questions.
Dear Pharmacist:
Remember to restore patient profile to Primary PBM after claim submission.
Restat has been authorized to reimburse you up to $35.00 plus an admin istra tion fee of $2.50 for processing this certificate when accompanied by a prescription for ZOVIRAX® (acyclovir) Ointment 5% or ZOVIRAX® (acyclovir) Cream 5% and allowing the patient up to $35.00 discount off your normal pharmacy charges for each product. Patient is responsible for the first $15.00 out of pocket expense for co-pay or pharmacy bill for each product, after which, the "up to" $35.00 rebate will apply. Any out of pocket balance or pharmacy bill exceeding a total of $50.00 per product will be patient's responsibility. This claim may be submitted electronically through Restat or by mail. For reimburse ment, please follow the instructions listed below. Retain the certificate and file with the prescription for auditing purposes.
Not valid with any other offer. One certificate per pharmacy visit.
This claim may be submitted one of the following 3 ways:
1. This claim may be submitted electronically through RESTAT. Submit all claims in NCPDP standard 5.1. Secondary processing should follow NCPDP standards for Copay Only billing, or in some cases using Coordination of Benefits processing, other coverage-code "8", dependent on your pharmacy software requirements. I f you have any questions regarding electronic submission, please call the RESTAT help desk at 1-866- 450-3277.
OR
2. If you are unable to transmit this claim electronically, please process under your standard format for a “paper claim” submission. Paper claims are to be submitted to RESTAT, 11900 W Lake Park Drive, Milwaukee, WI 53224.
OR
3. If you are unable to process this claim electronically or through your standard “paper claim” format, please return the voucher to the patient and instruct the patient to mail this voucher, along with the copy of their pharmacy receipt (cash register receipt not accepted), and their return address, to RESTAT, 11900 W Lake Park Drive, Milwaukee, WI 53224 for prompt payment of their rebate.
This coupon is not valid for prescriptions reimbursed under Medicare, Medicaid, or any other federal or state program, or where prohibited by law. Where third-party reimburse ment covers a portion of your prescrip tion, this coupon is valid only for the amount of your actual out-of-pocket expenses up to a maximum of $35.00 per product. Offer valid only for prescriptions filled in the United States. BTA Pharmaceuticals, Inc. reserves the right to discontinue this offer at any time. It is a violation of federal law to buy, sell, or counterfeit this certificate.
Offer void in Massachusetts except for patients with no prescription drug insurance coverage.
Offer Expires: June 1, 2012
ZOVIRAX is a registered trademark of GlaxoSmithKline.
© 2011 CORIA Laboratories, a division of Valeant Pharmaceuticals North America LLC ZOV2250211 March 2011