Program Terms, Conditions, and Eligibility Criteria: 1. This offer is valid only for eligible patients and is good for use only with a valid prescription for RHOFADE® (oxymetazoline HCI) cream, 1% at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. Depending on your insurance coverage, eligible patients may pay as little as $0 for up to 4 prescription fills of RHOFADE® cream, 1%. Check with your pharmacist for your co-pay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. 3. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO Insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this offer if they are Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. 4. Each card is valid for up to 4 prescription fills. Participating patients must have their first card use by 12/31/2019 and their final use by 12/31/2019. 5. Aclaris reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies. 7. Void if prohibited by law, taxed, or restricted. 8. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 9. This card has no cash value and may not be used in combination with any other discount coupon, discount card, rebate, free trial, or similar offer for the specified prescription. 10. This offer is not health insurance. 11. This card expires 12/31/2019. 12. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer. For questions about this program, please call 1-855-631-2485.
Pharmacist Instructions for a patient with an eligible third-party payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription.
Submit the claim to the primary third-party payer first and then submit the balance due to Change Healthcare as a Secondary Payer COB [coordination of benefits with patient responsibility amount and a valid Other Coverage Code, (e.g. 8)]. The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from Change Healthcare. Valid Other Coverage Code required.
For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-433-4893. Program managed by COMP on behalf of Aclaris.