Patient instructions: In order to redeem this offer you must have a valid prescription for Gvoke PFS, Gvoke HypoPen, and/or Gvoke Kit. Follow the dosage instructions given by the doctor. This offer may not be redeemed for cash. Offer not available for cash paying patients. 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.

 

For offer details and patients with questions, please call 1-877-myGvoke.

 

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. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

 

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 SS&C Health as a secondary payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code (eg, 8). Monthly and annual maximum caps may apply. Reimbursement will be received from SS&C Health.

 

Valid Other Coverage Code required. For any questions regarding SS&C Health online processing, please call the Help Desk at 1-844-616-9448.

 

Restrictions: This offer is valid in the United States and Puerto Rico. Offer not available for cash paying patients. 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. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable and is limited to 1 offer per person. Not valid if reproduced. Void where prohibited by law.

 

Program managed by ConnectiveRx on behalf of Xeris Pharmaceuticals, Inc. The parties reserve the right to rescind, revoke, or amend this offer without notice at any time.