For Patients:

  1. By using this coupon, you acknowledge that you meet the eligibility criteria and will comply with the terms and conditions.
  2. Present this coupon to your pharmacy along with a valid prescription for XOFLUZA and
  • You will pay the first $30
  • Genentech will pay up to the next $60 depending on your insurance coverage

Any additional amounts due are your responsibility.

If you have any questions, call 1-855-XOFLUZA.

For Pharmacists:

  1. The processing information on this card can be repeatedly used for all your patients.
  2. When you apply this offer, you are certifying that the patient meets the eligibility criteria, that you have not submitted and will not submit a claim for reimbursement under any state- or federally funded prescription insurance program for this prescription.
  3. For insured patients, process a coordination of benefits (COB/split bill) claim using the patient’s prescription insurance for the PRIMARY claim. Submit a SECONDARY claim using BIN 600428, PCN 06780000 and GROUP 06780145. For cash-paying or uninsured patients, submit a PRIMARY claim using BIN 600428, PCN 06780000, and GROUP 06780145. For help processing the coupon, please call 1-855-659-9767.

*Patient Eligibility/Terms and Conditions:

  1. This offer is valid for eligible patients receiving prescription XOFLUZA. It may be used by those with or without commercial/private insurance, including patients who choose to pay cash. This offer may not be used for any other product.
  2. This offer may not be used by patients in conjunction with prescription insurance under Medicaid, Medicare, TRICARE or similar federal or state programs. This offer is not health insurance or a benefit plan.
  3. Offer only valid in the United States and U.S. Territories. This offer is not transferable and may not be combined with any other offer.
  4. Offer must be presented along with a valid prescription for XOFLUZA at the time of purchase.
  5. The patient or their guardian must be 18 years or older to receive coupon benefits.
  6. May be used twice. Valid until September 30, 2020.
  7. Coupon program is void where prohibited by law and on the date an AB rated generic equivalent for XOFLUZA becomes available.
  8. Genentech USA, Inc. reserves the right to rescind, revoke, or amend this offer at any time without notice. It is a violation of federal law to buy, sell, or counterfeit this offer.

 

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