Bosentan Tablets for Oral Suspension

Eligibility Requirements:

• Not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any state- or federally funded program. This includes Medicare, Medigap, Medicaid, TRICARE®, Veterans Affairs (VA) or Department of Defense (DoD) health coverage, Employer Group Waiver Plans, or where prohibited, taxed or otherwise restricted by law.
• Must be a US resident.
• Must be 18 years of age or older to redeem this offer for yourself or a minor.

• Offer valid for up to 12 fills.
• A commercially insured patient with plan coverage for bosentan may pay as little as $0.
• Patient out-of-pocket costs may vary. Patient is responsible for any remaining balance after offer is applied and applicable taxes, if any.
• This co-pay card is not valid when the entire cost of a patient’s prescription drug is eligible for reimbursement from a private insurance plan or other health or pharmacy benefit programs.
• Patient and pharmacy agree not to seek reimbursement for all or any part of the benefit received by the patient through this offer from any third-party payer and are responsible for making any required reports of use of this offer to any third-party payer who pays any part of the prescription filled.
• Valid only at participating pharmacies in the US and Puerto Rico.
• No other purchase is necessary.
• This card and offer are not health insurance.
• The selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. Void if reproduced.
• Not valid with other offers. This offer has no cash value. No cash back.
• Lupin Pharmaceuticals, Inc. reserves the right to amend, revoke or terminate this offer without notice.
• By applying this offer, pharmacist is certifying that: (i) the patient meets the eligibility criteria, (ii) you have not submitted and will not submit a claim for reimbursement under any state or federal funding program for this prescription; and (iii) participation is not contrary to pharmacy agreements with third-party payers or laws or regulations applicable to pharmacies.
• Patient and pharmacist understand and agree to comply with the eligibility requirements and terms and conditions of this offer as described above.

• For a patient with an eligible third-party payer, submit the claim to the primary third-party payer first and then submit the balance due as a Secondary Payer COB [coordination of benefits with patient responsibility amount and a valid Other Coverage Code (e.g., 8)].
• The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Valid Other Coverage Code required.
• For any questions regarding online processing please call 1-347-252-3204.