Patient Pays 1st $20
Coupon Pays up to Next $10
Patient pays balance greater than $30
Uses: Notuss-NX & Notuss-NXD temporarily relieves the
following symptoms due to the common cold, hay fever
(allergic rhinitis) or other upper respiratory allergies: • runny
nose • sneezing • itching of the nose or throat • itchy,
watery eyes • cough due to minor throat and bronchial
irritation. Notuss-NXD relieves these additional symptoms: •
nasal congestion • swelling of the nasal passages.
Claims Processor RESTAT
BIN # 600471 Group # X 5570 Rx PCN# 7777
Cardholder ID#
Attention Patient: If your total out of pocket pharmacy
bill for Notuss-NX or Notuss-NXD exceeds $20, present this
certificate to the pharmacist for an instant rebate of “up to”
$10. If your total out of pocket pharmacy bill exceeds $30,
you will be responsible for the additional balance. Not valid
with any other offer.
Remember to restore patient profile to Primary PBM
after claim submission.
Expiration Date: May 15, 2012
To Ensure Reimbursement, you will need:
- BIN #, Group #, Cardholder ID #, and Rx PCN #
- Standard prescription information
- Person code: Enter 001.
Remember to restore patient profile to Primary PBM
after claim submission.
Call 1-866-450-3277 with processing questions. |
Dear Pharmacist:
Remember to restore patient profile to Primary PBM after claim submission.
RESTAT has been authorized to reimburse you up to $10.00,
plus an administration fee of $2.25 for processing Notuss NX
and Notuss NXD and allowing the patient up to a $10.00
discount off your normal pharmacy charges. Patient is
responsible for the first $20.00 out of pocket expense for co-pay
or pharmacy bill, after which the “up to” $10.00 rebate will
apply. Any out of pocket balance or pharmacy bill exceeding a
total of $30.00 will be patient’s responsibility. This claim may
be submitted electronically through RESTAT or by mail. For
reimbursement, please follow the instructions listed below.
Retain this certificate and file with your prescription for
auditing purposes.
Not valid with any other offer. One certificate per pharmacy visit.
This claim may be submitted one of the following 3 ways:
1. This claim may be submitted electronically through RESTAT.
Submit all claims in NCPDP standard 5.1. Secondary
processing should follow NCPDP standards for Copay Only
billing, or in some cases using Coordination of Benefits
processing, other coverage-code “8”, dependent on your
pharmacy software requirements. I f you have any questions
regarding electronic submission, please call the RESTAT help
desk at 1-866- 450-3277.
OR
2. If you are unable to transmit this claim electronically, please
process under your standard format for a “paper claim”
submission. Paper claims are to be submitted to RESTAT,
11900 W Lake Park Drive, Milwaukee, WI 53224.
OR
3. If you are unable to process this claim electronically or
through your standard “paper claim” format, please return
the voucher to the patient and instruct the patient to mail this
voucher, along with the copy of their pharmacy receipt
(cash register receipt not accepted), and their return
address, to RESTAT, 11900 W LAKE PARK DRIVE,
MILWAUKEE, WI 53224 for prompt payment of their rebate.
Void where prohibited by law, taxed or restricted. Not valid
for patients insured by Medicare, Medicaid, or another federal
health insurance program including any state pharmacy
assistance programs, or in the state of Massachusetts, except
for cash-paying patients. Void outside USA. Void if reproduced.
It is illegal for any person to sell, purchase or trade, or offer
to sell, purchase or trade, or to counterfeit this voucher.
SJ Pharmaceuticals reserves the right to rescind, revoke or
amend this offer without notice.
Offer Expires: May 15, 2012
© 2011 SJ Pharmaceuticals, LLC. All Rights Reserved  |