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| Dear Pharmacist: |
RESTAT has been authorized to reimburse you up to $20.00 plus an administration fee of $4.00 for processing this certificate when accompanied by a prescription for Encora, and allowing the patient up to $20.00 discount off your usual and customary charge. This claim may be submitted electronically through RESTAT or by mail. For reimbursement, please follow the instructions listed below. Retain the certificate and file with the prescription for auditing purposes.
Not valid with any other offer. One certificate per fill.
This claim may be submitted one of the following three ways. |
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1. |
This claim may be submitted electronically through RESTAT. Submit all claims in NCPDP standard 3.0 or greater. Retain the certificate and file with the prescription for auditing purposes. If you have any questions regarding electronic submission, please call the RESTAT help desk at 1-800-248-1062 for additional help regarding Coordination of Benefit claims. |
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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, P.O. Box 758, West Bend, WI 53095. |
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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 and their return address to RESTAT, P.O. Box 758, West Bend, WI 53095, for prompt payment of their rebate. |
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This coupon is not valid for prescriptions reimbursed under Medicare, Medicaid or any other federal or state program, or where prohibited by law. Where third-party reimbursement covers the patient's prescription, this coupon is valid only for
the amount of the patient's actual expenses up to a maximum of $20.00. |
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