First prescription may be free. You may pay no more than $10 for subsequent prescriptions.*
Click on the image to download the Savings Card.
*Eligible patients will pay as little as $0 of the patient’s co-pay or out-of-pocket expenses of MOTOFEN®. A valid Prescriber ID# is required on the prescription.
Patient Instructions: In order to redeem this offer you must have a valid prescription for MOTOFEN and follow the dosage instructions given by the doctor. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the MOTOFEN savings offer should call 1-844-218-0448.
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. As a condition of payment, you certify that you are in compliance with all program rules, terms, and conditions, as well as with any obligations to provide notice of your participation in this program to third-party payers as required by law, contract, or otherwise.
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 COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). Eligible patients are responsible to pay $0 for the first prescription of 24-30 tablet supply with a max cap of $207; for 31-60 tablet supply with a max cap of $413 & 61-90 tablet supply with a max cap of $619 & 91-100 tablet supply with a max cap of $688.
For sequential prescriptions eligible patients are responsible to pay as little as $10 for 24-30 tablet supply with a max cap of $207; for 31-60 tablet supply with a max cap of $413 & 61-90 tablet supply with a max cap of $619 & 91-100 tablet supply with a max cap of $688. Reimbursement will be received from CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604.
RESTRICTIONS: This offer is valid in the United States. 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). 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 payor of the existence and/or value of this offer. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable. Void where prohibited by law. Program managed by ConnectiveRx on behalf of Sebela Pharmaceuticals Inc. The parties reserve the right to rescind, revoke or amend this offer without notice at any time. Expiration date: 12/31/2019.