XIFAXAN Instant Savings Card
Eligible patients may pay no more than $0 each month for XIFAXAN
With the XIFAXAN Instant Savings Card, eligible patients* with commercial insurance
covering XIFAXAN may pay no more than $0 for their XIFAXAN prescription.
*Eligibility Criteria, Terms and Conditions: This offer is only valid for patients with commercial insurance, including commercially insured patients
without coverage for Xifaxan. Patients without commercial insurance are not eligible. For eligible commercially insured patients with coverage for Xifaxan, Salix Pharmaceuticals will pay the patient’s co-payment for each eligible prescription fill using the savings card up to a maximum amount of $300 per fill on quantity of 1-20 pills dispensed, $500 per fill on quantity
of 21-41 pills dispensed, $1,200 per fill on quantity of 42 pills and more dispensed. For eligible commercially insured patients without coverage for Xifaxan, the patient must pay the first $50 of out-of-pocket expense and then Salix Pharmaceuticals will pay the remaining out-of-pocket expense up to the maximum amount of $300 per fill on quantity of 1-20 pills dispensed, $500 per fill on quantity of 21-41 pills dispensed, $1,200 per fill on
quantity of 42 pills and more dispensed. Patient is responsible for all additional costs and expenses after application of the maximum benefits. This savings card can be used up to 12 times per calendar year. This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health
Insurance Plan, or any other federal or state health care programs. This offer is only good in the USA at participating retail pharmacies. This offer cannot be redeemed at other locations, including government-subsidized clinics or facilities. This offer is not valid where otherwise prohibited, taxed,
or otherwise restricted. Patient is responsible for reporting receipt of copay assistance to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the copay card, as may be required. This offer cannot be combined with other offers. This card
has no cash value. No other purchase is necessary. This offer is nontransferable. No substitutions are permitted.
This card is not health insurance. You understand and agree to comply with the terms and conditions of this offer as set forth above. Salix Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice. This offer expires on December 31, 2018.