With the DYANAVEL XR, QUILLIVANT XR, or QUILLICHEW ER Savings Card, eligible commercially-insured and cash-paying patients can lower their out-of-pocket costs for their prescription. Eligible insured patients may pay as little as $20, and the card pays up to the maximum benefit. Program benefit calculated on FDA-approved dosing. Offer valid for up to 12 uses by 3/31/2020. A valid Prescriber ID# is required on the prescription.
See Full Prescribing Information for each product, including Boxed Warning about Abuse and Dependence, and Medication Guide, at www.trispharma.com.
This program is valid through 3/31/2020.
Patients with questions about the Tris Savings offer should call 1-844-865-8684.
Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.
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 Change Healthcare as a Secondary Payer as a copay-only billing using a valid Other Coverage Code, (e.g. 8). The patient may pay as little as $20 and the card pays up to the maximum benefit. Reimbursement will be received from Change Healthcare.
Pharmacist instructions for a cash-paying patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (e.g. 1, 3) is required. The patient is responsible for the first $20 and the card pays up to the maximum benefit. Reimbursement will be received from Change Healthcare.
For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-422-5604.
Restrictions: This offer is valid in the United States. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, TRICARE, or other federal or state health programs (such as medical assistance programs). Cash Discount Cards and other non-insurance plans are not valid as primary under this offer. If the patient is eligible for drug benefits under any such program, the patient cannot use this offer. By using this offer, the patient certifies that he or she will comply with any terms of his or her health insurance contract requiring notification to his or her payer of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. Program expires 3/31/2020. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. Program managed by ConnectiveRx on behalf of Tris Pharma. Tris Pharma reserves the right to rescind, revoke, or amend this offer without notice at any time.