Claims Processor: SimpleSaveRx
Rx PCN#: 55101202
Person Code: 01
Cardholder ID#: 83701000001
*Attention Patient: Present this coupon voucher to your pharmacist along with your insurance card and valid prescription of Vanoxide® HC Lotion Or Dritho-Creme®. Keep this coupon voucher for future savings on your refill prescriptions.
With the use of this voucher, Insured Patients with aprescription drug plan should Pay No More Than $35 for each prescription.
Maximum benefit limits apply and are subject to change at any time.
Please restore patient profile to Primary PBM after claim submission. Not valid with any other offer. One certificate per pharmacy visit.
SimpleSaverRx has been authorized to reimburse you up to the program maximum, which is subject to change, after Insured Patients pay the first $35. Any remaining amounts due after the use of this voucher are the responsibility of the patient.
For reimbursement, please follow the instructions listed below.
1. This claim may be submitted electronically through SimpleSaverRx. Submit all claims in NCPDP standard D.0. Secondary processing should follow NCPDP standards for Copay Only billing (OCC8, or OCC3 if the primary insurance does not cover the brand); or in some cases using Coordination of Benefits processing, dependent on your pharmacy software requirements. If you have any questions regarding electronic submission, please call the Help Desk at 844-SAVE4RX (844-728-3479).
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 SimpleSaveRx, 3350 N Arizona Ave, Ste 2, Chandler, AZ 85225.
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 prescription receipt (cash register receipts are not accepted), and their return address, to SimpleSaveRx, 3350 N Arizona Ave, Ste 2, Chandler, AZ 85225 for prompt payment of their rebate.
This offer is not valid on prescriptions reimbursed under Medicare, Medicaid, or any other federal or state program, or where prohibited by law. Where third-party reimbursement covers a portion of your prescription, this coupon is valid only towards the amount of the patients actual out-of-pocket expenses, up to the program maximum. Only Commercial Insurance is valid to qualify for the “Insured Patient” benefit. Pharmacy Discount or Cash Cards are not valid as the primary insurance. Offer valid only for prescriptions filled in the United States. Marnel Pharmaceuticals reserves the right to rescind, revoke or adjust this offer at any time. It is a violation of federal law to buy, sell, or counterfeit this certificate.
Call 1-844-SAVE4RX (844-728-3479) with processing questions.
©2018 Marnel Pharmaceuticals