Divigel® Copay Savings Card Terms & Conditions

  • Strengths/NDCs covered by this program include:
    • Divigel 0.5 mg – 68025-066-30
    • Divigel 0.75 mg – 68025-083-30
    • Divigel 1.0 mg – 68025-067-30
    • Divigel 1.25 mg – 68025-086-30
  • Strengths/NDCs not covered by this program include:
    • Divigel 0.25 mg – 68025-065-30
  • 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 as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient pay amount for a 30-day supply will be reduced up to $25 (after the patient pays the first $25). The patient pay amount for a 60-day supply will be reduced up to $50 (after the patient pays the first $50). For a 90-day supply, the patient pay amount will be reduced up to $75 (after the patient pays the first $75). Offer valid for select NDCs. 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 (e.g. 1) is required. The patient pay amount for a 30-day supply will be reduced up to $25 (after the patient pays the first $25). The patient pay amount for a 60-day supply will be reduced up to $50 (after the patient pays the first $50). For a 90-day supply, the patient pay amount will be reduced up to $75 (after the patient pays the first $75). Offer valid for select NDCs. 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 Rules – Eligibility, Terms, & Conditions: This offer is valid in the United States. Program may be rescinded, revoked, or amended at any time without notice. Not valid for patients who are covered by any state or federally funded healthcare program, including but not limited to Medicare (Part D or otherwise), Medicaid, Medigap, CHAMPUS, TRICARE, and any state pharmaceutical assistance program; for patients who are Medicare eligible and enrolled in an employer-sponsored health plan or prescription benefit program for retirees; or patients whose insurance plan is paying the entire cost of this prescription. The coupon program is not health insurance and the patient is responsible for complying with any obligations as may be required by his/her insurance provider. Void outside of the US and Puerto Rico or where prohibited by law, taxed, or restricted. By participating in the coupon program, you are certifying that you understand and agree to comply with the terms and conditions of this program as set forth above. Card has no cash value. Card is not transferable and cannot be combined with any other offer. It is a violation of federal law to buy, sell or counterfeit this card.
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