*Applies to commercially insured patients, individual out-of-pocket costs may vary. Program eligibility and restrictions apply.
This offer is good only with a valid prescription for Forfivo XL. Where third-party reimbursement covers a portion of your prescription, this offer is valid only if your out-of-pocket expense for each prescription exceeds $28. A maximum savings benefit of up to $175 for ≤59 tablets; up to $350 for 60-89 tablets; or up to $525 for ≥90 tablets applies; out of pocket costs may vary. Offer is not valid for prescriptions being fully or partially reimbursed under Medicaid, a Medicare drug benefit plan, or other federal or state program (such as medical assistance programs). The patient is responsible for reporting receipt of this offer to any health plan, health insurer, or third-party payer as may be required. By using this offer you agree that you will not submit a claim for the prescription to any government payer. If any part of your prescription is paid for by a nongovernmental third-party payer, you attest to having disclosed this offer to your third-party payer. The use of this card is subject to applicable state and federal law. Void where prohibited or restricted. This offer is not health insurance. Offer expires upon program termination by Almatica Pharma Inc.(“Almatica”) who reserves the right to rescind, revoke, or amend this program without notice.
1Godfrey, AR. Single dose crossover comparative bioavailability study of bupropion hydrochloride 450 mg extended release tablets and Wellbutrin XL® 150 mg extended release tablets in healthy male volunteers under fasting and fed conditions [clinical study report]. Laval, QC: Algorithme Pharma Inc; 2011.
FORFIVO XL® is a registered trademark of IntelGenx Corp. Wellbutrin XL is a registered
trademark of GlaxoSmithKline.