*Out-of-pocket costs may vary based on insurance coverage. Limitations apply. Please note,
this offer is not available for patients eligible for Medicare, Medicaid, or any other
public payer coverage. See full Terms and Conditions for eligibility and restrictions.
with coverage may pay as little as $15
per device for their prescription of QNASL with a maximum benefit $98.10 per
device. Maximum Reimbursement limits apply and out of pocket expenses may vary.
Commercially Insured patients whose insurance does not cover QNASL will pay $75
per device for their prescription of QNASL. Teva will pay the remaining balance. Non-insured and cash-paying
patients: Teva will pay up to $98.10 per device. Maximum Reimbursement limits apply and out of pocket expenses
Patients are not eligible if prescriptions are paid for in part or full by any state or federally funded
programs, including but not limited to Medicare, Medicaid, Medigap, VA, DOD, TRICARE, or by private health
benefit programs which reimburse for the entire cost of prescription drugs. This card is not valid for
patients who are Medicare eligible and are enrolled in an employer-sponsored health plan or prescription
drug benefit program for retirees (i.e., patients who are eligible for Medicare Part D but receive a
prescription drug benefit through a former employer). Cash Discount Cards and other non-insurance plans
are not valid as primary under this offer. If the patient is eligible for drug benefits under any such
program, the patient cannot use this offer. By redeeming this offer, the patient certifies that he or she
will comply with any terms of his or her health insurance contract requiring notification to his or her
payor of the existence and/or value of this offer and that the patient is eligible for, and will comply
with, the terms of this offer. By redeeming this offer, the patient and the pharmacist acknowledge that
the patient is eligible, and the patient and pharmacist understand and agree to comply with the Terms and
Conditions of this offer. If the patient is a minor, this offer must be redeemed by the patient’s parent,
guardian or caregiver. Offer not valid for patients under 4 years of age.
Void if copied, transferred, purchased, altered or traded and where prohibited and restricted by law.
This is not an insurance program. Valid only in the United States including the Commonwealth of Puerto Rico.
This offer may not be used with any other discount, coupon or offer. This offer
expires on December 31, 2019. This program is managed by ConnectiveRx on behalf of Teva Pharmaceuticals USA,
Inc. Teva reserves the right to limit, change or discontinue this offer at any time without notice. If you
have any questions regarding your eligibility or benefits, please call 833-378-7362.
In order to redeem this offer you
must have a valid prescription for QNASL. Follow the dosage instructions given by the
doctor. This offer must be presented along with your prescription for QNASL and your primary
insurance card. Non-Insured/Cash Paying Patients: In order to redeem this
offer you must have a valid prescription for QNASL. Follow the dosage instructions given
by the doctor. This offer must be presented along with your prescription for QNASL. Patients
with questions about the QNASL Savings Offer should call 833-378-7362.
By redeeming this offer, the Pharmacist certifies
that QNASL is being dispensed to a patient eligible for this offer in compliance with
these Terms and Conditions and the Pharmacy has not submitted and will not submit a claim for
reimbursement under any federal, state, or other governmental program for this prescription. For
any questions regarding Change Healthcare online processing, please call the Help Desk at
1-800-422-5604. For Commercially-Insured Patients: Please submit
this claim to the primary Third-Party Payer first, then submit the balance due to Change
Healthcare as a Secondary Payer COB (coordination of benefits) with patient responsibility and a
valid Other Coverage Code (e.g. 8). Reimbursement will be received from Change Healthcare.
For Insured/Not Covered: Patients who have commercial insurance but you
receive a “not covered” response because QNASL is not on the patient’s formulary or is
subject to prior authorization or step therapy and the patient has not met the criteria, continue the
claim adjudication process and run the claim as secondary payer COB with the patient responsibility
amount and a valid Other Coverage Code (e.g., 03). For Cash-Paying Patients:
Please submit this claim to Change Healthcare. A valid Other Coverage Code (e.g., 01) is required.
For QNASL, the patient’s card will have a value of $98.10 per device towards
their prescription. Reimbursement will be received from Change Healthcare.