Co-pay Card

With the Co-pay Card,* eligible patients could PAY AS LITTLE AS $25 for each prescription

*Terms and Conditions apply.

  • This co-pay card is not health insurance.
  • The co-pay card is only accepted at participating pharmacies.
  • For any questions, please call 1-877-776-7246.
  • No membership fees required.
  • Eligible insured patients' savings limited to $140 per 30 days for up to 12 uses within the offering period.
  • Card may be used once every 30 days.
  • Maximum savings of $1680 per year.
  • Cash paying patients' savings limited to $100 per 30 days for up to 12 uses within the offering period.
  • Card may be used once every 30 days.
  • Maximum savings of $1200 per year.
Co-pay Card Terms and Conditions
 

By using the Quillivant XR and QuilliChew ER Co-pay Card, you acknowledge that you currently meet the eligibility criteria and will comply with the Terms and Conditions described below:

  • Co-pay cards are not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare, or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico [formerly known as “La Reforma De Salud”])
  • Co-pay cards are not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs that reimburse you for the entire cost of your prescription drugs
  • Insureds must be 18 or older; patients must be 6 or older
  • Eligible insured patients may pay as little as $25 for each prescription
  • If your out-of-pocket costs are $165 or less, you will pay $25
  • If your out-of-pocket costs are more than $165, you will save $140 off your costs
  • Savings are limited to $140 per 30 days for up to 12 uses within the offering period
  • Card may be used once every 30 days. Maximum savings of $1680 per year
  • Each patient is limited to one active co-pay card at a time during this offering period and the co-pay cards are not transferable
  • Cash payers will receive up to $100 off each prescription fill
  • If your out-of-pocket costs are $125 or less, you will pay $25
  • If your out-of-pocket costs are more than $125 you will save $100 off your costs
  • Savings are limited to $100 per 30 days for up to 12 uses within the offering period
  • Card may be used once every 30 days. Maximum savings of $1200 per year
  • You must deduct the value received under this program from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf
  • The co-pay card cannot be combined with any other rebate or coupon, free trial, or similar offer for the specified prescription
  • The co-pay card will be accepted only at participating pharmacies
  • This co-pay card is not health insurance
  • This coupon is not valid where prohibited by law
  • This offer is good only in the United States and Puerto Rico
  • Tris Pharma, Inc. reserves the right to rescind, revoke, or amend the co-pay card without notice
  • Offer valid from 1/1/17 to 12/31/2019. No membership fees apply

For help with the Quillivant XR and QuilliChew ER Co-pay Card, call 1-877-776-72461-877-776-7246.