This offer is good for commercially insured and cash-paying patients
purchasing Trokendi XR® extended-release capsules and may not be used for
any other product. This offer is not valid for prescriptions purchased under Medicaid,
Medicare or other federal or state programs (such as medical assistance programs).
Offer not valid where prohibited by law, taxed, or restricted. It is not transferable
and may not be combined with any other offer. The amount of the rebate cannot exceed
the patient's actual out-of-pocket expenses up to a maximum of $200 per prescription.
Offer must be presented along with a valid prescription for Trokendi XR®
at the time of purchase. By enrolling into this program you are
consenting to the collection and use of certain personal information including your
phone number and/or email address and elements of pharmacy claim information. This
information will be collected and used by service providers of Supernus Pharmaceuticals,
Inc. (“Supernus”), in order to administer this program. This information is not provided
to Supernus directly. If you do not consent, please do not enroll into the program.
If you require additional assistance, please call 1-866-398-0833. This offer expires
12/31/2015. Supernus reserves the right to rescind, revoke, or amend this offer
without notice at any time.
This card is provided to you as a service by your doctor and Supernus Pharmaceuticals,
Inc. The patient should present a valid prescription for Trokendi XR® (topiramate)
extended-release capsules when redeeming this card. Prescriber ID#
required on prescription. This card is valid towards out-of-pocket expenses for
Trokendi XR®. If the patient’s total cost per prescription is more
than $10, this program will cover the amount above $10 (up to a maximum of $200
per prescription) on each of the next 12 prescriptions for up to a 30-day supply
of Trokendi XR® of any dosage strength filled. Patients with questions
please call 1-866-398-0833.
Pharmacist instructions for a patient with an Eligible 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 COB (coordination
of benefits) with patient responsibility amount and a valid Other Coverage Code
(eg, 8). The patient pays the first $10. This program will cover
the amount above $10 (up to a maximum of $200 per prescription) on 12 prescriptions
for up to a 30-day supply of Trokendi XR® of any dosage strength
filled. Reimbursement will be received from Therapy First Plus.
Please include a Medication Guide with each Trokendi XR® prescription.
Pharmacist instructions for a cash paying patient: Submit the claim
to Therapy First Plus. A valid Other Coverage Code (eg, 1)
is required. The patient pays the first $10. This program will cover the amount
above $10 (up to a maximum of $200 per prescription) on 12 prescriptions for up
to a 30-day supply of Trokendi XR® of any dosage strength filled.
Reimbursement will be received from Therapy First Plus.
For any questions regarding Therapy First Plus online processing,
please call the Help Desk at 1-800-422-5604.
Offer expires 12/31/2015. Limit one card per patient. Offer not
valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan
or other federal or state programs (such as medical assistance programs). If you
are eligible for drug benefits under any such program, you cannot use this card.
Program managed by PSKW, LLC on behalf of Supernus Pharmaceuticals, Inc. The parties
reserve the right to amend or terminate this program at any time without notice.
Product dispensed only pursuant to program rules and federal and state laws.
This is not insurance.
Patients with questions?
Trokendi XR is a registered trademark of Supernus Pharmaceuticals, Inc.
©2014 Supernus Pharmaceuticals, Inc. All rights reserved. SPN.TRO.2014-0229