Pay Only $15.00*
on Co-Pays up to $50.00
|Claims Processor RESTAT|
|BIN # 600471
||Group # X 4150
||Rx PCN# 7777
|Cardholder ID # 1543019
||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: December 31, 2012
To Ensure Reimbursement, you will need:
- BIN #, Group #, Cardholder ID #, and Rx PCN # (use numbers above)
- 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.
Remember to restore patient profile to Primary PBM after
Restat has been authorized to reimburse you up to $35.00 plus
an administration 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 reimbursement,
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:
- This claim may be submitted electronically through RESTAT.
Submit all claims in D.0. 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. If you have any questions regarding
electronic submission, please call the RESTAT help desk
at 1-866- 450-3277.
- 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.
- 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 reimbursement covers
a portion of your prescription, 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. Valeant Dermatology reserves the right to
discontinue this offer at any time. It is a violation of federal law
to buy, sell, or counterfeit this certificate.
The patient is responsible for reporting receipt of this offer
to any health insurer, health plan, or third-party payor as may
Offer Expires: December 31, 2012
ZOVIRAX is a registered trademark of GlaxoSmithKline.
©2012 Valeant Dermatology,
a division of Valeant Pharmaceuticals North America LLC
ZOV322A0712 July 2012