NUVIGIL® (armodafinil) Tablets [C-IV]

Prescription Savings Card

PATIENT INSTRUCTIONS

Save on NUVIGIL Prescriptions*

Present the NUVIGIL Prescription Savings Card to your pharmacist and your co-pay will
be as low as $5 per prescription on NUVIGIL prescriptions (maximum savings of up to $50
per prescription).* Please bring this offer to your pharmacist when you fill your
prescription; it contains important instructions for the pharmacist. By redeeming
this offer, you certify that you are eligible for this offer in accordance with the
Terms and Limitations section below. Please note that this offer cannot
be redeemed by patients eligible for Medicare (including Medicare
Advantage or Part D Prescription Drug Plans), Medicaid or
other public payment programs.

Get the Prescription Savings Card

*Limitations apply.

PHARMACIST INSTRUCTIONS

First Prescription FREE

  • Submit primary claim to your patient's insurance provider for up to 30 NUVIGIL tablets; the patient's insurance may require a Prior Authorization ("PA") for NUVIGIL prescriptions
  • Submit a secondary transaction using Other Coverage Code:
    • 03 if primary insurance has denied coverage, or
    • 08 to reduce the patient's co-pay expense
  • The secondary transaction should be submitted to AlphaScrip, BIN 610600, PNC: AS, using the Group number and Card ID located on the card
  • The patient will receive up to 30 tablets at no cost, subject to terms and limitations
  • If your patient's insurance provider requires a Prior Authorization ("PA") for their NUVIGIL prescription, please initiate the PA process to help your patient save on future NUVIGIL prescriptions
  • If you have questions regarding prior authorization or need forms to assist your patient initiate the prior authorization process, please go to www.CoverMyMeds.com for assistance

Prescription Refills — Patient's Co-pay as low as $5

  • Submit primary claim to your patient's insurance provider
  • Submit a secondary transaction using Other Coverage Code 08 to reduce the patient's co-pay expense
  • The secondary transaction should be submitted to AlphaScrip, BIN 610600, PNC: AS, using the Group # and Card ID located on the card
  • Patient's out-of-pocket expense will be as low as $5 for each prescription refill with a maximum savings of up to $50 per prescription

Pharmacist Certification and Agreement:

By accepting and redeeming this offer, the pharmacist certifies that (i) NUVIGIL has been dispensed to a patient eligible for this offer in accordance with the Terms and Limitations below; and (ii) participation in this program complies with all applicable laws and contractual or other obligation as a pharmacy provider. Pharmacist agrees to accept the reimbursement offered for the first prescription under this offer and not charge the patient any amounts over and above the offered reimbursement.

For full prescribing information, visit www.NUVIGIL.com

Terms and Limitations:

Offer expires 12/31/2014. Valid only in the United States at participating retail pharmacies and cannot be redeemed at government-subsidized clinics. Offer must be accompanied by a valid prescription for NUVIGIL. Void where prohibited by law. No substitutions permitted. Offer not valid for patients eligible for coverage for NUVIGIL under Medicare (including Medicare Advantage or Part D Prescription Drug Plans), Medicaid or other public payment programs (e.g., TRICARE, or any state program). Depending upon the nature and terms of your relationship with insurance carriers, you will report offer redemption to the insurance carrier if required. Offer not valid for prescriptions reimbursed in full (including co-pay) by any third party payor. Offer cannot be combined with any other voucher, certificate, coupon, rebate, or similar offer. It is illegal for any person to sell, purchase, or trade; or to offer to sell, purchase, or trade or to counterfeit this offer. This is not an insurance program. Cephalon reserves the right to rescind, revoke, or amend this offer without notice. Offer not extended on prescriptions for:

  • Patients using mail-order or institution-based pharmacies to fill their prescriptions, or who are federal or state government employees
  • Patients who are filling their prescriptions at nonparticipating pharmacies
  • Patients over age 65 (due to Medicare eligibility) or under age 18

Additional Terms and Limitations:

  • Insured patients only
  • Minimum supply of 14 tablets per fill
  • Maximum of three card uses per month
  • One card per patient
  • Cash value of the coupon is 1/100 of a cent

By redeeming this offer, patients and pharmacists understand and agree to comply with these Terms and Limitations.

For questions regarding processing, please call the AlphaScrip Pharmacy Help Desk at 1-877-274-3244.