Velphoro HCP Download Coupon

Velphoro HCP Coupon

004682

CN

WCVPH6311

01214630710

Please see terms and conditions below. Restrictions may apply. Keep this savings card coupon for future refills of Velphoro.

Terms and Conditions:

To the Patient: You must present this card to the pharmacist along with your insurance card (if you have one) and your prescription (at each refill) to participate in this program. You can use this card only with new or existing valid prescriptions for VELPHORO; it is valid toward out-of-pocket expense only. You are not eligible to participate in this program if you are enrolled in a state or federally funded prescription drug program. This includes Medicare, Medicare Advantage, Medicare Part D, Medicaid, Medicaid Managed Care, Medigap, Veterans Affairs, Department of Defense programs, or TriCare or any similar state-funded program such as a state pharmacy assistance program. You are not eligible to participate if you are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription benefit for retirees. If you are enrolled in a state or federally funded prescription insurance program, you may not use this card even if you elect to be processed as an uninsured (cash-paying) patient. When you use this card, you are certifying that you understand and will comply with the program rules, regulations, and terms and conditions. Limit one savings card per patient for VELPHORO.

To the Pharmacist: When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental program. For a cash-paying patient: Submit this claim to Therapy First Plus. A valid Other Coverage Code is required. The patient will pay $0 copay* with a maximum of up to $1,500.00 on each month's prescription.† You will receive this amount in your reimbursement from Therapy First Plus plus a handling fee. For a patient paying with an Authorized Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to Therapy First Plus as a Secondary Payer as a copay only billing using Other Coverage Code 8. The patient will receive up to $1,500.00 off each month's prescription, the patient will be responsible for any remaining balance, and you will receive this in your reimbursement from Therapy First Plus plus a handling fee. You must comply with all contractual obligations you have with Third-Party Payers, and must provide notice to all payers as required by law, contract, or otherwise. Other Coverage Code required.

For any questions regarding Therapy First Plus online processing, please call the Pharmacist Help Desk at 1-800-433-4893. Program may be cancelled at any time without notice. Void where prohibited by law. This card must be returned upon request, and is the property of Fresenius Medical Care, who retains the rights to rescind, revoke, or amend this program without notice. Not valid for patients eligible for benefits under Medicaid (including Medicaid managed care), Medicare, TriCare, Veterans Affairs, FEHBP, or similar state or federal programs. Offer good only in the USA and Puerto Rico.

*The majority of commercially insured patients will have no out-of-pocket costs. Out-of-pocket costs include copay, coinsurance, and deductible.

†Up to $500 off prescriptions for 90 tablets or less; up to $1,000 off prescriptions for 91–180 tablets; up to $1,500 off prescriptions for 181 tablets or more.