- By using this coupon, you acknowledge that you meet the
eligibility criteria and will comply with the terms and
- 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.
- The processing
information on this card can be repeatedly used for all your
- 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.
- 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:
- 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
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.
- 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.
- Offer must be presented along
with a valid prescription for XOFLUZA at the time of purchase.
- The patient or their guardian must be 18 years or older to
receive coupon benefits.
- May be used twice. Valid until September 30, 2020.
- Coupon program is void
where prohibited by law and on the date an AB rated generic
equivalent for XOFLUZA becomes available.
- 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.