Patient Instructions: In order to redeem this card you must have a valid prescription for at least 3 Stendra® (avanafil) tablets. Eligible patients will pay the first $15 and the card will pay up to $25 for each tablet up to a maximum of 18 tablets. Offer valid for up to 15 uses. Follow the dosage instructions given by the doctor. Prescriber ID# required on prescription.
Restrictions: This offer is not valid for prescriptions covered by or submitted for reimbursement under Medicaid, Medicare, or similar federal or state programs including any medical assistance programs. This offer is not valid for those under 18 years of age. This card may not be redeemed for cash. Program expires 12/31/2018. Cardholders with questions, please call 1-844-274-2837.
Pharmacist Instructions for a patient with an eligible third party: Submit the claim to the primary third party payer first, then submit the balance due to CHANGE HEALTHCARE as a secondary payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 8). The patient pays the first $15 and the card will pay up to $25 for each tablet up to a maximum of 18 tablets. 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 (eg 1) is required. The patient pays the first $15 and the card will pay up to $25 for each tablet up to a maximum of 18 tablets. Reimbursement will be received from CHANGE HEALTHCARE.
Valid Other Coverage Code required. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604.
Program managed by ConnectiveRx on behalf of MIST Pharmaceuticals. MIST reserves the right to rescind, revoke or amend this offer without notice at any time. Not valid if reproduced. Void where prohibited by law.