Print and present this certificate to your pharmacist and receive up to $60.00 OFF your prescription.
Please follow all dosing instructions provided by your healthcare professional.

Note: for best printing results go to File/Print Preview and select shrink to fit before printing, you can also reduce size

Patient Pays 1st $10
Coupon Pays up to Next $60
Patient pays balance greater than $70

Minimum 40 Capsule Prescription

Uses: UTA is indicated for the treatment of symptoms of irritative voiding. UTA relieves local symptoms such as inflammation, hypermotility, and pain, which accompany lower urinary tract infections. UTA also relieves symptoms caused by diagnostic procedures.

Claims Processor RESTAT
BIN # 600471 Group # X 5881 Rx PCN# 7777
Cardholder ID#

Attention Patient: Minimum 40 capsule prescription
needed to qualify. If your total out of pocket pharmacy bill for UTA exceeds $10, present this certificate to the pharmacist for an instant rebate of “up to” $60. If your total out of pocket pharmacy bill exceeds $70, you will be responsible for the additional balance. Minimum prescription of 40 capsules is required. Not valid with any other offer.

Remember to restore patient profile to Primary PBM
after claim submission.

Expiration Date: July 31, 2013

To Ensure Reimbursement, you will need:

  • BIN #, Group #, Cardholder ID #, and Rx PCN #
  • Standard prescription information
  • Person code: Enter 001.

Remember to restore patient profile to Primary PBM
after claim submission.

Call 1-866-450-3277 with processing questions.

Dear Pharmacist:
Remember to restore patient profile to Primary PBM after claim submission.
Minimum 40 capsule prescription needed to qualify for rebate. RESTAT has been authorized to reimburse you up to $60.00, plus an administration fee of $2.25 for processing this certificate when accompanied by a prescription for UTA (minimum of 40 capsules) and allowing the patient up to a $60.00 discount off your normal pharmacy charges. Patient is responsible for the first $10.00 out of pocket expense for co-pay or pharmacy bill, after which the “up to” $60.00 rebate will apply. Any out of pocket balance or pharmacy bill exceeding a total of $70.00 will be patient’s responsibility. This claim may be submitted electronically through RESTAT or by mail. For reimbursement, please follow the instructions listed below. Retain this certificate and file with your prescription for auditing purposes.
Not valid with any other offer. One certificate per pharmacy visit.
This claim may be submitted one of the following 3 ways:

1. This claim may be submitted electronically through RESTAT. Submit all claims in NCPDP standard D.0. Secondary processing should follow NCPDP standards for Copay Only billing, or in some cases using Coordination of Benefits processing, other coverage-code “8”, dependent on your pharmacy software requirements. I f you have any questions regarding electronic submission, please call the RESTAT help desk at 1-866- 450-3277.
OR
2. If you are unable to transmit this claim electronically, please process under your standard format for a “paper claim” submission. Paper claims are to be submitted to RESTAT, 11900 W Lake Park Drive, Milwaukee, WI 53224.
OR
3. If you are unable to process this claim electronically or through your standard “paper claim” format, please return the voucher to the patient and instruct the patient to mail this voucher, along with the copy of their pharmacy receipt (cash register receipt not accepted), and their return address, to RESTAT, 11900 W LAKE PARK DRIVE, MILWAUKEE, WI 53224 for prompt payment of their rebate.

Void where prohibited by law, taxed or restricted. Not valid for patients insured by Medicare, Medicaid, or another federal health insurance program including any state pharmacy assistance programs, or in the state of Massachusetts, except for cash-paying patients. Void outside USA. Void if reproduced. It is illegal for any person to sell, purchase or trade, or offer to sell, purchase or trade, or to counterfeit this voucher.

SJ Pharmaceuticals reserves the right to rescind, revoke or amend this offer without notice.

Offer Expires: June 31, 2013

© 2011 SJ Pharmaceuticals, LLC. All Rights Reserved