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Note: Circassia provides prescription drug samples to some healthcare professionals licensed to prescribe medications, as authorized by law.
For US Healthcare Professionals
For US Healthcare Professionals
Note: Circassia provides prescription drug samples to some healthcare professionals licensed to prescribe medications, as authorized by law.
Eligible commercially insured patients with a valid prescription for Tudorza® Pressair® (aclidinium bromide inhalation powder) who present this savings card at participating pharmacies will pay $10 per 30-day supply (1 inhaler) if their out-of-pocket cost is more than $10. Patients who pay cash for their prescription will not pay more than $10 for each prescription. This offer is good for 12 uses and each inhaler counts as 1 use. Other restrictions may apply. Patient is responsible for applicable taxes, if any. Card expires on 12/31/2020. If patient has any questions regarding this offer, please call 1-844-892-7872.
Non-transferable, limited to one per person, cannot be combined with any other offer. Void where prohibited by law, taxed or restricted. Patients, pharmacists, and prescribers cannot seek reimbursement from health insurance or any third party for any part of the benefit received by the patient through this offer.
Circassia reserves the right to rescind, revoke, or amend this offer, eligibility and terms of use at any time without notice. This offer is not conditioned on any past, present or future purchase, including refills. Offer must be presented along with a valid prescription for TUDORZA PRESSAIR at the time of purchase.
If a patient’s commercial insurance plan does not cover TUDORZA PRESSAIR, use of this offer permits his/her healthcare provider or pharmacy to share limited information with certain Circassia vendors to determine if additional resources may be available, and to act on his/her behalf to initiate any processes that may be necessary to access these resources.
BY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE.
Pharmacist Instructions for a Patient With an Eligible Third-Party Payer: For Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 8. This will reduce the eligible patient’s out-of-pocket costs to $10 on a 30-day supply.
For Insured/Not Covered Patients: Submit the claim to the primary Third-Party Payer first, if the primary claim submission shows a managed care restriction (step-edit, prior authorization or NDC block), continue the claim adjudication process and submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code of 3. This will reduce an eligible patient’s out-of-pocket costs to $10 on a 30-day supply. Reimbursement will be received from Change Healthcare.
Pharmacist Instructions for a Cash-Paying Patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (eg, 1) is required. Reimbursement will be received from Change Healthcare.
Valid Other Coverage Code Required. For any questions regarding online processing, please call Circassia Connect at 1-844-892-7872.
Program managed by ConnectiveRx, on behalf of Circassia.
You may be eligible for this offer if you are insured by commercial insurance and your insurance does not cover the full cost of your prescription, or you are not insured and are responsible for the cost of your prescriptions.
Patients who are enrolled in a state or federally funded prescription insurance program are not eligible for this offer. This includes patients enrolled in Medicare Part D, Medicaid, Medigap, Veterans Affairs (VA), Department of Defense (DOD) programs or TriCare, and patients who are Medicare eligible and enrolled in an employer-sponsored group waiver health plan or government-subsidized prescription drug benefit program for retirees.
If you are enrolled in a state or federally funded prescription insurance program, you may not use this savings card even if you elect to be processed as an uninsured (cash-paying) patient.
This offer is not insurance, is restricted to residents of the United States and Puerto Rico, and to patients over 18 years of age. If you use a mail-order pharmacy, please contact your pharmacy provider to confirm if this offer will be accepted.
PP-TUD-US-0051 7/19