Eligibility RULES AND Regulations
To The Patient
Present this card to your pharmacist along with your prescription for LEXIVA® (fosamprenavir calcium), EPZICOM® (abacavir sulfate and lamivudine), COMBIVIR® (lamivudine/zidovudine), TRIZIVIR® (abacavir sulfate, lamivudine, and zidovudine), EPIVIR® (lamivudine), ZIAGEN® (abacavir sulfate), RETROVIR® (zidovudine), SELZENTRY® (maraviroc), RESCRIPTOR® (delavirdine) and/or VIRACEPT® (nelfinavir).
Retain this card for future use. In order to be eligible for this offer: (a) where third-party reimbursement covers a portion of your prescription, this coupon is valid only for the amount of your actual out-of-pocket cost up to a maximum of $100.00 for each valid prescription for any product(s) listed on this card, (b) your prescription MUST NOT be covered and/or reimbursed by a federal healthcare program, including Medicare or Medicaid, or by any similar federal or state program, including a state pharmaceutical assistance program, and (c) you MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (ie, you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer).
Further, if you are a resident of Massachusetts, this offer is valid only if you are paying the entire cost of the prescription yourself (ie, your insurance does not cover any of the cost of your prescription). This offer may be applied to multiple prescriptions for the ViiV Healthcare products mentioned on this card.
In the case of multiple prescriptions, you must satisfy the eligibility requirements for each prescription. This offer may not be used with any other discount, coupon, or offer. Your acceptance of this offer must be consistent with the terms of any drug benefit provided by your health insurer, health plan, or private third-party payor, and you agree to report acceptance of this offer to your health insurer, health plan, or third-party payor as may be required.
Only an original savings card will be accepted, and must be presented to your pharmacist at the time you have the prescription filled–not valid if reproduced. Offer good only in USA. Not transferable. ViiV Healthcare reserves the right to rescind, revoke, or amend this offer without notice. Void where prohibited by law, taxed, or restricted. Limit of up to $100.00 per prescription.
By tendering this card, I, Patient or Parent/Legal Guardian of the Patient, certify that I am at least 18 years of age and that: (i) I have read the above
terms, (ii) I will not submit a claim for reimbursement under any federal, state, or other governmental program for this prescription, (iii) if I am Medicare eligible, I am not enrolled in an employer-sponsored health plan or prescription drug plan for retirees, and (iv) I will otherwise comply with the terms above. It is a violation of federal law to buy, sell, or counterfeit this savings card.
Call the ViiV Healthcare Response Center at 1-877-844-8872 for any questions about the savings card program.
To The Pharmacist
Please dispense any of the following products [LEXIVA® (fosamprenavir calcium), EPZICOM® (abacavir sulfate and lamivudine), COMBIVIR® (lamivudine/zidovudine), TRIZIVIR® (abacavir sulfate, lamivudine, and zidovudine), EPIVIR® (lamivudine), ZIAGEN® (abacavir sulfate), RETROVIR® (zidovudine), SELZENTRY® (maraviroc), RESCRIPTOR® (delavirdine) and/or VIRACEPT® (nelfinavir)] at up to $100 off the patient's out-of-pocket cost for each prescription and return the card to the patient for future use. This claim may be submitted electronically through OPUSHealth using the information on the front of this card. Submit all claims in NCPDP standard 5.1. Secondary processing should follow NCPDP standards for copay–only billing, or in some cases using Coordination of Benefits processing, dependent on your pharmacy software requirements. You will be reimbursed a fee of $2.50 plus the discount offered to the patient directly from OPUSHealth. Offer valid only for prescriptions filled in the US. ViiV Healthcare reserves the right to discontinue this offer at any time. It is a violation of federal law to buy, sell, or counterfeit this coupon.
Call the OPUSHealth help desk at 1-800-364-4767 for processing questions.
By redeeming this card, I certify that (i) I have received this card from an eligible patient, (ii) I have dispensed the product(s) as indicated, (iii) I have not submitted, and will not submit, a claim for reimbursement to the patient or any federal, state, or other governmental payor, and (iv) I will otherwise comply with the terms hereof. I further certify that my participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that I have as a pharmacy provider.