Valuable prescription savings for eligible* patients.
Per fill for eligible commercially insured patients with product coverage
Per fill for eligible commercially insured patients without product coverage
Cash paying patients may save up to $140 per fill
No need to submit prior authorizations
Delivery options available in some locations
*Terms and Conditions apply; see below
With the Tris Assist Pharmacy Program, eligible commercially insured and cash-paying patients can lower their out-of-pocket costs for their prescription.
*Eligible commercially-insured patients with product coverage may pay as little as $0 per fill and the card pays up to the maximum benefit. Patients without product coverage may pay $50 per fill and the card pays up to the maximum benefit. Program benefit calculated on FDA-approved dosing. Offer valid in US for up to 12 uses by 12/31/2021. A valid Prescriber ID# is required on prescription. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, TRICARE, or other federal or state health programs (such as medical assistance programs). Cash Discount Cards and other non-insurance plans are not valid as primary under this offer.
This offer is not health insurance. Offer expires 12/31/2021. Accepted only at participating pharmacies. By using this offer, you acknowledge that you currently meet the eligibility criteria and will comply with the Terms and Conditions. This offer is valid for eligible patients who are filling a prescription for DYANAVEL XR (amphetamine), Quillivant XR (methylphenidate HCl), or QuilliChew ER (methylphenidate HCl).
Please see Full Prescribing Information, for DYANAVEL XR, Quillivant XR, and QuilliChew ER, including Boxed Warning regarding Abuse and Dependence, and Medication Guide, at the links shown below.
TERMS AND CONDITIONS
This offer is valid toward one of the following products: • DYANAVEL XR • QUILLIVANT XR • QUILLICHEW ER
See Full Prescribing Information for DYANAVEL XR, Quillivant XR, and QuilliChew ER, including Boxed Warning about Abuse and Dependence, and Medication Guide, at www.trispharma.com.
With the Tris Assist Pharmacy Program, eligible commercially insured and cash-paying patients can lower their out-of-pocket costs for their prescription. Eligible commercially insured patients with product coverage may pay as little as $0 per fill, and the card pays up to the maximum benefit. Patients without product coverage may pay as little as $50 per fill, and the card pays up to the maximum benefit. Cash paying patients may save up to $140 per fill. Program benefit calculated on FDA-approved dosing. Offer valid for up to 12 uses by 12/31/2021. A valid Prescriber ID# is required on the prescription.
This program is valid through 12/31/2021.
Patients with questions about the Tris Assist Pharmacy Program should call 1-888-840-7006.
Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.
Pharmacist instructions for insured patients: Submit the claim to the primary Third Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer as a copay-only billing using a valid Other Coverage Code, (e.g. 8). Eligible commercially insured patients with product coverage may pay as little as $0 per fill, and the card pays up to the maximum benefit. Patients without product coverage may pay as little as $50 per fill, and the card pays up to the maximum benefit. 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 (e.g. 0, 1) is required. Patients may save up to $140. The patient is responsible for any remaining balance due after savings offer has been applied. Reimbursement will be received from Change Healthcare.
For any questions regarding Change Healthcare online processing, please call the Help Desk at 1-800-422-5604.
Restrictions: This offer is valid in the United States. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, TRICARE, or other federal or state health programs (such as medical assistance programs). Cash Discount Cards and other non-insurance plans are not valid as primary under this offer. If the patient is eligible for drug benefits under any such program, the patient cannot use this offer. By using this offer, the patient certifies that he or she will comply with any terms of his or her health insurance contract requiring notification to his or her payer of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. Program expires 12/31/2021. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. Tris Pharma reserves the right to rescind, revoke, or amend this offer without notice at any time.
