Co-pay Savings Terms and Conditions

Program Terms, Conditions, and Eligibility Criteria

1. This offer is valid only for eligible patients and is good for use only with a valid prescription for vitaMedMD brand prenatal vitamins or Prena1 generic prenatal vitamins at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. Depending on your insurance coverage, eligible patients may pay $25 or less on each of up to twelve (12) 30-day prescriptions; $75 or less on each of up to four (4) 90-day prescriptions. Check with your pharmacist for your co-pay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. 3. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO Insurance plans that reimburse you for the entire cost or your prescription drugs. 4. Void outside the United States and its territories or where prohibited by law, taxed, or restricted. 5. This card is not health insurance, is not redeemable for cash, and is not transferable. Not valid with any other offer. 6. TherapeuticsMD, vitaMedMD, and BocaGreenMD (collectively, the Companies) reserve the right to amend or end this program at any time without notice. Data related to the patient's redemption with this Co-pay Card may be collected, analyzed, and shared with the Companies for market research and other purposes related to assessing coupon and rebate programs. Any data will be aggregated and de-identified. 7. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about this program please call 1-855-993-2665.

Authorization to Contact

I understand and consent to TherapeuticsMD contacting me using the information provided on this form to enroll me in, operate, and administer TherapeuticsMD's patient support services and/or programs as described, including promotional communications by telephone or SMS/text. I understand that the operation and administration of certain of these services and/or programs may require TherapeuticsMD to contact me by telephone or SMS/text, or other communication vehicles and standard charges may apply.

TherapeuticsMD's Privacy Pledge to Patients

TherapeuticsMD respects our customers and takes the protection of their privacy very seriously. TherapeuticsMD pledges the following:

  • TherapeuticsMD does not and will not sell or rent your information to marketing companies or mailing list brokers.
  • TherapeuticsMD is careful to only collect and/or use personal identifiable information for the purposes stated in this Authorization and as necessary to provide the services and/or programs in which the patient or customer enrolls.
  • TherapeuticsMD practices are consistent with federal and state privacy laws, including HIPAA.
  • TherapeuticsMD program enrollment is voluntary and always provides patients with an easy option to cancel participation.

Pharmacist Instructions for a patient with an eligible third-party payer:When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription.

  • Submit the claim to the primary third-party payer first and then submit the balance due to Change Healthcare as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g., 3 or 8). The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. 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 1-800-433-4893. Program managed by COMP on behalf of TherapeuticsMD.

 

© 2018 TherapeuticsMD, Inc.



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