PLENVU^® Medicare Part D Coupon Program

Welcome

The PLENVU^® Medicare Part D Coupon Program is sponsored by Salix Pharmaceuticals and designed to help reduce your out-of-pocket cost for PLENVU^® if your Medicare Part D plan does not cover the product, or your out-of-pocket costs exceed $60*, and you opt out of using your Medicare Part D prescription benefit in conjunction with this offer.

Please note that you have the option to use existing prescription coverage if you have it. If you elect to take advantage of this offer, you will need to opt out of using your Medicare Part D prescription benefit and agree to certain conditions.

To receive your PLENVU^® Medicare Part D coupon, please complete the requested information below.

*Terms, conditions and limitations apply. Most eligible patients may pay as little as $60. Please see below for the program’s full Eligibility Criteria, Terms and Conditions.

Please fill out the highlighted required fields below.

* Required fields.

Please enter the date of birth of the patient who will use this coupon. *

!You must be 18 years of age or older to redeem this offer for yourself or a minor.

Please enter the 5-digit zip code of the residence of the patient who will use this coupon. *

!Please enter a valid 5-digit zip code.

Please enter the phone number of the patient who will use this coupon. *

!Please enter a valid phone number.

You must agree to each of the following statements to be eligible for the Part D Coupon Program:

I have Medicare Part D coverage or I am a Medicare Advantage patient. I do not have coverage through Medicaid, Tricare, DOD Tricare, VHA, IHS, SCHIP, or any other state or federal health programs. *

Agree

Disagree

I agree to not seek reimbursement from my Medicare or Medicare Advantage prescription plan for my out-of-pocket costs for PLENVU^® purchased with the card. I will not count the cost of PLENVU^® toward my deductible or true out-of-pocket cost. *

Agree

Disagree

I will purchase all of my prescriptions for PLENVU^® before the end of the year using this card, and I will not use my Medicare Part D benefits for PLENVU^® at any time during this calendar year, even if my benefits change. *

Agree

Disagree

I will notify my prescription plan that I have purchased PLENVU^® outside my benefit by sending the form letter provided by Salix Pharmaceuticals to the plan. *

Agree

Disagree

Is the patient who will be using this card interested in receiving additional communications (health tips, wellness tools, coupons, other discounts, educational materials, product information, etc) from Salix Pharmaceuticals? *

Yes

I authorize Salix Pharmaceuticals, and companies working with or for it, to communicate with me by email or text message, about products, including marketing materials, health conditions, co-pay and financial assistance. I agree to be contacted at the email and/or phone number I provided. Consent is not a condition of purchase of goods or services. For Privacy Policy go to https://www.bauschhealth.com/privacy. Salix Pharmaceuticals and companies providing services to Salix Pharmaceuticals will not sell or rent your personally identifiable information, as described in the Privacy Policy. *

Yes

Please confirm that, by clicking submit to activate this coupon, you have read, understand and will comply with the terms and conditions of the program and that you currently meet all eligibility criteria. *

Yes

ELIGIBILITY CRITERIA/TERMS AND CONDITIONS:

PLENVU^® Medicare Part D Coupon Program is valid for a cost reduction of a qualifying prescription of PLENVU^® for eligible patients.
PLENVU^® Medicare Part D Coupon Program can only be used by eligible patients one time for PLENVU^®.
You must have a prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
You must agree to not seek reimbursement from your Medicare or Medicare Advantage prescription plan for your out-of-pocket costs for PLENVU^® purchased with the card.
You must also agree not to count the cost of PLENVU^® toward your deductible or true out-of-pocket cost.
You must notify your prescription plan that you have purchased PLENVU^® outside of your benefit by sending the form letter provided by Salix Pharmaceuticals at www.myPLENVU.com.
Program is not valid for any patients with commercial/private insurance, uninsured patients, or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE.
No other purchase necessary.
PLENVU^® Medicare Part D Coupon Program card is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer not already associated with this offer.
PLENVU^® Medicare Part D Coupon Program card is not insurance.
PLENVU^® Medicare Part D Coupon Program card can be used at mail order pharmacies.
PLENVU^® Medicare Part D Coupon Program card is the property of Salix Pharmaceuticals and must be turned in on request.
It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase trade, or counterfeit the PLENVU^® Medicare Part D Coupon Program card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the PLENVU^® Medicare Part D Coupon Program card must agree to the following conditions: Patient must agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for PLENVU^® purchased with the card.
Patient must also agree not to count the cost of PLENVU^® toward their deductible or true out-of-pocket cost.
Patient must notify prescription plan that PLENVU^® has been purchased outside of benefit by sending the form letter provided by Salix Pharmaceuticals at www.myPLENVU.com.
The patient must purchase all prescriptions for PLENVU^® before the expiration date on the card and the patient must not use Medicare Part D benefit for PLENVU^®.
PLENVU^® Medicare Part D Coupon Program card can be used only by eligible United States residents (including Puerto Rico, Guam and the US Virgin Islands) at participating eligible retail pharmacies in the United States. Product must originate from the United States.
Salix Pharmaceuticals reserves the right to rescind, revoke, or amend this offer at any time without notice.
Data related to your redemption of the PLENVU^® Medicare Part D Coupon Program card may be collected, analyzed, and shared with Salix Pharmaceuticals, for market research and other purposes related to assessing patient savings programs. Data shared with Salix Pharmaceuticals will be aggregated and de-identified, meaning it will be combined with data related to other card redemptions and will not identify the patient.
For questions call: 1-866-686-0138.

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Legal Notice

PLENVU^® is a registered trademark of the Norgine group of companies used under license.
PLV.0093.USA.21 v2.0 ©2022 Salix Pharmaceuticals or its affiliates. January 2022

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