*BRING THIS COUPON TO YOUR PHARMACIST FOR COPAY SAVINGS.
 

TO THE PATIENT:
You must present this coupon along with your prescription to participate in this program. You must activate this coupon before using by visiting https://copaysavingsprogram.com/110/Xerese, calling 1-866-686-0122, or texting "XERESE" to 24109. Messaging and data rates may apply.

This offer is only valid for patients who have commercial insurance, and for cash-pay patients who are 65 years of age or younger and do not have any insurance. Patients with government insurance are not eligible. Maximum benefits and number of uses apply. For more information on maximum benefits and number of uses please visit www.xerese.com or call 1-866-686-0122. When you use this coupon you are certifying that you are an eligible patient and understand and agree to abide by the program rules, regulations, eligibility requirements, and terms and conditions.

This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs or for anyone 65 years of age or older without commercial insurance. OraPharma reserves the right to rescind, revoke, or amend this offer at any time without notice. This offer expires on December 31, 2019.

For pharmacy processing questions, please call 1-844-373-0987.
 

TO THE PHARMACIST:
This offer is only valid for patients who have commercial insurance, and for cash-pay patients who are 65 years of age or younger and do not have any insurance. Patients with government insurance are not eligible. Maximum benefits and number of uses apply.

For eligible patients who have commercial insurance, submit the claim to the primary Third Party Payer first, then submit the balance due to DST Pharmacy Solutions as a Secondary Payer as a copay only billing using BIN 019158 and a valid Other Coverage Code (e.g. 8). Reimbursement will be received from DST Pharmacy Solutions.

For eligible cash paying patients who are 65 years of age or younger and do not have any insurance, submit the claim to DST Pharmacy Solutions using BIN 019158. A valid Other Coverage Code (e.g. 1) is required.

For any questions regarding DST Pharmacy Solutions online processing, please call 1-844-373-0987. 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.

When you process this coupon you are certifying that that the patient is eligible under this program and you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.

By accepting this coupon and submitting claims, you also agree to all other program terms and conditions, which are posted at www.xerese.com.

OraPharma reserves the right to rescind, revoke, terminate, or amend this offer at any time without notice. This offer expires on December 31, 2019.