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    Xofluza-Coupon CC ERXPROMO

    Uploaded by

    traviscrs
    This document provides information about a coupon program that offers up to $60 off the cost of a XOFLUZA prescription. It outlines the terms and conditions of the program and provides processing instructions for pharmacists.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Xofluza-Coupon CC ERXPROMO

    Uploaded by

    traviscrs
    29 views1 page
    This document provides information about a coupon program that offers up to $60 off the cost of a XOFLUZA prescription. It outlines the terms and conditions of the program and provides processing instructions for pharmacists.

    Original Description:

    Coupon for.flu stuff

    Original Title

    xofluza-coupon.cc.ERXPROMO

    Copyright

    © © All Rights Reserved

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    This document provides information about a coupon program that offers up to $60 off the cost of a XOFLUZA prescription. It outlines the terms and conditions of the program and provides processing instructions for pharmacists.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views1 page

    Xofluza-Coupon CC ERXPROMO

    Uploaded by

    traviscrs
    This document provides information about a coupon program that offers up to $60 off the cost of a XOFLUZA prescription. It outlines the terms and conditions of the program and provides processing instructions for pharmacists.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    No activation required.

    Pay as $
    little as
    for your XOFLUZA prescription,
    30 PROCESSING INFORMATION

    up to $60 off. *
    RxBIN 610020
    Group 99994457
    PCN S6
    *Terms and conditions apply. Member ID ERXPROMO

    For Patients: For Pharmacists:


    1. 
    By using this coupon, you acknowledge that you meet the 1. 
    The processing information on this card can be repeatedly
    eligibility criteria and will comply with the terms and conditions. used for all your patients.
    2. Present this coupon to your pharmacy along with a valid 2. When you apply this offer, you are certifying that the patient meets
    prescription for XOFLUZA and the eligibility criteria, and that you have not submitted and will not
    submit a claim for reimbursement under any state- or federally
    • You will pay the first $30
    funded prescription insurance program for this prescription.
    • Genentech will pay up to the next $60 depending on your
    insurance coverage 3. For insured patients, process a coordination of benefits
    (COB/split bill) claim using the patient’s prescription insurance
    Any additional amounts due are your responsibility.
    for the PRIMARY claim. Submit a SECONDARY claim using BIN
    3. May be used twice. Valid until September 30, 2024. 610020, PCN S6 and GROUP 99994457. For cash-paying or
    uninsured patients, submit a PRIMARY claim using BIN 610020,
    PCN S6, and GROUP 99994457. For help processing the coupon,
    If you have any questions, call 1-855-XOFLUZA. please call 1-855-659-9767.

    Patient Eligibility/Terms and Conditions:


    1.  Program is only available for commercially insured patients. 4. It is only valid for Genentech medicines and only valid in
    Patients using Medicare, Medicaid or any other government- the U.S. and U.S. Territories.
    funded program to pay for their Genentech medicines are
    5. The coupon is not health insurance or a benefit plan.
    not eligible.
    6. The Program is void where prohibited by law and shall follow
    2. This Coupon is only available to those patients who are
    state restrictions in relation to AB-rated generic equivalents
    taking the Genentech medicine for an FDA-approved
    where applicable (such as MA, CA).
    indication, and it cannot be combined with any other
    rebate/Coupon, free trial or similar offer for the specified
    prescription.
    3. The Patient or their guardian must be 18 years of age or older.

    ©2023 Genentech USA, Inc. All rights reserved. 1 DNA Way, South San Francisco, CA 94080-4990 M-US-00006500(v5.0)

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