• This oﬀer is valid only for eligible patients, 18 years and older, and is good for use only with a valid prescription for Talicia® (omeprazole, amoxicillin and rifabutin) at the time the prescription is ﬁlled by the pharmacist and dispensed to the patient.
• Depending on your insurance coverage, eligible patients may pay as little as $35 and the card pays up to the maximum beneﬁt for each product. Check with your pharmacist for your copay discount. Maximum savings limit applies; patient out-of-pocket expense may vary.
• This oﬀer is valid only for patients with commercial/private insurance and is not valid for prescriptions that are eligible to be reimbursed in whole or part by Medicare, Medicaid, or a Medicare Part D Plan, Tricare, VA, DoD, Puerto Rico Government Health Insurance Plan, 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. Patients without insurance coverage are considered “cash-pay” patients. Medicare Part D enrollees who are in the prescription drug coverage gap (the “donut hole”) are not eligible for the co-pay coupon. Patients who begin receiving prescription beneﬁts from such Government Programs at any time will no longer be eligible to use the card.
• RedHill Bipharma, Inc. reserves the right to rescind, revoke, or amend this offer without notice.
• Oﬀer good only for use by eligible residents of the USA, including Puerto Rico, at participating retail, specialty, or mail-order pharmacies.
• Void where prohibited by law, taxed, or restricted.
• This card is not transferable. No substitutions are permitted. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.
• 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. Patient may not be currently receiving drug assistance through any RedHill Biopharma Inc. patient assistance programs.
• This oﬀer is not health insurance and is not intended to substitute for insurance. Patient, pharmacist and prescriber agree not to seek reimbursement for all or any part of the beneﬁt received by the patient through the oﬀer.
• Both patient and pharmacist are each individually responsible for reporting receipt of coupon beneﬁt to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription ﬁlled using the card, as required.
• 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. The card may not be redeemed more than once per 30 days per patient. Certain information pertaining to your use of the card may be shared with RedHill Biopharma Inc., the sponsor of the card, and/or its vendors. The information disclosed will include the date the prescription is ﬁlled and the amount of your co-pay that will be paid for by using this card.
For questions about the program please call 1.844.825.4242 (844-TALICIA).
• 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. 3 or 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.
• Submit this claim to Change Healthcare. A valid Other Coverage Code (e.g., 0 or 1) is required. 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 RedHill Bipharma, Inc.