* Valid for up to 12 months of refills through 12/31/2017. Offer not valid on 25 count test strips. ELIGIBLE PRIVATELY INSURED PATIENTS pay the first $15 of co-pay on Rx of 300 test strips or less. CASH PATIENTS can receive savings up to $25 per month. RESTRICTIONS: Offer not valid for prescriptions reimbursed under Medicaid, Medicare drug benefit plan, Tricare or other federal or state health programs (i.e. medical assistance programs). If patient is eligible for drug benefits under any such program, offer not valid. Visit ContourChoice.com for additional benefit details and Restrictions. Void where prohibited. For Questions: Call 1-855-226-3931. Patient: BY USING THIS CARD, YOU UNDERSTAND AND AGREE TO COMPLY WITH THE RESTRICTIONS. YOU ALSO CERTIFY THAT YOU WILL COMPLY WITH ANY TERMS OF YOUR HEALTH INSURANCE CONTRACT REQUIRING THAT YOUR PAYOR BE NOTIFIED OF THE EXISTENCE AND/OR VALUE OF THIS OFFER. Pharmacist: By applying this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription, and that you will comply with the Restrictions. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. Pharmacist instructions for a patient with an Eligible Third Party: Submit claim to the primary Third Party Payer first, then submit the balance due to Therapy First as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). Patient is responsible for the first $15 and the card covers up to $35 of remaining co-pay on prescriptions of 300 test strips or less. For quantities over 300 test strips, patient contributions and card benefits increase accordingly – up to $45 and $105 respectively. Reimbursement will be received from Therapy First. Pharmacist instructions for a cash paying patient: Submit this claim to Therapy First. A valid Other Coverage Code (e.g. 1) is required. Patient is responsible for the first $15 and the card covers up to $25 per month. Reimbursement will be received from Therapy First. Valid Other Coverage Code required. For any questions regarding Therapy First online processing, please call the Help Desk at 1-800-422-5604. Offer expires 12/31/17.
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