PROGRAM TERMS, CONDITIONS, AND ELIGIBILITY CRITERIA
Offer is valid for commercially insured patients only. Most eligible commercially insured patients will pay as little as $35 (maximum benefit amount of
$100) for Nucynta® ER or Nucynta® tablets. Any remaining out-of-pocket expense will be the patient’s responsibility. This offer is valid in the United
States. Some restrictions may apply. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, Tricare or other
federal or state health programs (such as medical assistance programs). 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 using 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 payer of the
existence and/or value of this offer. This offer is not valid for cash paying patients. Offer not valid for patients under 18 years of age.
Patient Instructions: To redeem this offer, you must have a valid prescription for Nucynta® ER or Nucynta® and follow the dosage instructions
provided by your healthcare provider with a valid Prescriber ID# (e.g. NPI or DEA). This offer may not be redeemed for cash. Patients with questions
about the Nucynta® ER or Nucynta® savings offer should call 1‑844‑807‑0348.
Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other
governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider.
Pharmacist instructions for a patient with an Eligible Third Party Payer: Submit the 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 amount and a valid Other
Coverage Code (e.g. 8). Most eligible commercially insured patients will pay as little as $35 (maximum benefit amount of $100) for Nucynta® ER or
Nucynta® tablets. 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 expires 06/30/2019.
This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. Program managed by
ConnectiveRx on behalf of Collegium Pharmaceutical. The parties reserve the right to rescind, revoke or amend this offer without notice at any time.