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PLENVU® Co-pay Assistance Card
Print and bring this savings offer to the pharmacy when you fill your PLENVU® prescription.

BIN: 019158 PCN: CNRX GROUP: AC68037002 ID:

FOR PHARMACISTS:

STEPS FOR PROCESSING THE PLENVU® SAVINGS OFFER FOR COMMERCIALLY INSURED PATIENTS WITH OR WITHOUT COVERAGE FOR PLENVU®

	Submit the claim to the patient’s primary commercial insurance.
	Submit the balance due to SS&C Health (SS&C) as a secondary payer with an Other Coverage Code (OCC) of 08.
	In some cases, the patient’s primary commercial insurance may reject the claim due to a prior authorization, step-edit, or NDC block.
	If this occurs, submit the secondary claim with an OCC of 03.*
	For any questions regarding SS&C online processing, please call the Help Desk at 1‑844‑373‑0987.
	* OCC of 03 indicates that the patient is insured, but the drug is not covered. Do not use an OCC code of 00 or 01 for a patient that has primary insurance coverage.

*Maximum benefits and other restrictions apply. Please see below for the program’s full Eligibility Criteria, Terms, and Conditions.

Please see full Prescribing Information at www.myPLENVU.com.

Eligibility Criteria and Terms and Conditions: This offer is only valid for patients 18 years of age or older. Eligible insured patients with coverage for PLENVU® must pay the first $55 of their co-pay, and eligible insured patients without coverage for PLENVU® must pay the first $75 of out-of-pocket expense. Maximum benefit applies. For information about maximum benefits, please visit www.myPLENVU.com and/or call the helpline at 1-855-202-3208. This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs. This offer is only good in the USA at participating retail pharmacies. This offer cannot be redeemed at other locations, including government-subsidized clinics or facilities. This offer is not valid where otherwise prohibited, taxed, or otherwise restricted. Patient is responsible for reporting receipt of co-pay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the co-pay card, as may be required. This offer cannot be combined with other offers. This card has no cash value. No other purchase is necessary. This offer is nontransferable. No substitutions are permitted. This card is not health insurance. You understand and agree to comply with the terms and conditions of this offer as set forth above. Salix Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice.

To the Patient: You must present this card, along with your prescription, to participate in this program. When you use this card you are certifying that you are 18 years of age or older and understand and agree to the program rules, regulations, eligibility requirements, and terms and conditions. This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs. Salix Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice.

To the Pharmacist: When you process this card, you are certifying that the patient is 18 years of age or older and that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription. This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other government programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs. Salix Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice.

For eligible commercially insured patients: Submit the claim to the primary Third Party Payer first, then submit the balance due to SS&C as a Secondary Payer as a copay only. Bill using BIN 019158 and a valid Other Coverage Code (eg, 08). Reimbursement will be received from SS&C. If coverage is rejected due to a prior authorization, step-edit, or NDC block, patients are still considered eligible.

For patients who are commercially insured, but product is not covered: Submit this claim to SS&C as a secondary payer using BIN 019158. A valid Other Coverage Code (eg, 03)* is required. Reimbursement will be received from SS&C.

For a cash-paying patient: Submit this claim to SS&C as a secondary payer using BIN 019158. A valid Other Coverage Code (00/01) is required. Reimbursement will be received from SS&C. Cash-paying patients will pay $75.

For any questions regarding SS&C Health online processing, please call the Help Desk at 1‑844‑373‑0987.

* Other Coverage Code (OCC) of 03 indicates that the patient is insured, but the drug is not covered. Do not use an OCC code of 00 or 01 for a patient that has primary insurance coverage.

PLENVU is a registered trademark of the Norgine group of companies used under license.
The Salix logo is a trademark of Salix Pharmaceuticals affiliated entities.
© 2024 Salix Pharmaceuticals or its affiliates. Printed in USA. PLV.0090.USA.21V4.0
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