‡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 calling 1-866-686-0122, texting "XERESE" to 24109, or by visiting https://copaysavingsprogram.com/110/Xerese.
When you use this coupon you are certifying that you understand and agree to 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.
TO THE PHARMACIST:
When you use this coupon, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription.
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.
Cash paying patients, submit this 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 the Help Desk at 1-844-373-0987
This offer is only valid for patients with commercial insurance and eligible uninsured patients.
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 use this coupon you are certifying that 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. This offer is not valid for any person eligible for reimbursement of prescriptions in whole or in part, by any of these programs.
By accepting this coupon and submitting claims for any of the products specified here in you agree to the program terms and conditions, which are posted at www.xeresesavings.com.
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.
OraPharma affiliated entities reserves the right to rescind, revoke, terminate, or amend this offer at any time, without notice. This offer expires on December 31, 2019.