Please complete the form below to receive your patient savings voucher for up to $15 after paying the first $50 of the co-pay or cash price.
Terms and conditions apply, see below for more details.
Up to program maximum, which is subject to change.
* Indicates a required field.
To Patient: Present this card to your pharmacy along with a valid prescription for SUPREP. You will receive savings of 30% off your remaining out-of-pocket expenses, up to a maximum of $15 after paying the first $50 of your co-pay or cash price. Any additional amounts due are your responsibility. This offer is limited to one use and is not transferable. By using this card, you acknowledge that you meet the eligibility criteria and will comply with the terms and conditions. If you have any questions, call 1-833-844-6441.
Pharmacist instructions for Commercially Insured Patient: Submit the claim to the primary Third Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code, (e.g. 8, 3). The patient pay amount submitted will be reduced by up to $15.00 and reimbursement will be received from Change Healthcare.
Pharmacist instructions for a cash paying patient: Submit this claim to Change Healthcare. A valid Other Coverage Code (e.g. 0,1) is required. The patient pay amount submitted will be reduced by up to $15.00 and reimbursement will be received from Change Healthcare.
IMPORTANT SAFETY INFORMATION
SUPREP® Bowel Prep Kit (sodium sulfate, potassium sulfate and magnesium sulfate) Oral Solution is an osmotic laxative indicated for cleansing of the colon as a preparation for colonoscopy in adults and pediatric patients 12 years of age and older. DOSAGE AND ADMINISTRATION: Each bottle must be diluted with water to a final volume of 16 ounces (Adults) and 12 ounces (Pediatric patients 12 years of age and older). Must consume additional water after each dose. Stop consumption of all fluids at least 2 hours prior to the colonoscopy. CONTRAINDICATIONS: Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction or ileus, bowel perforation, toxic colitis or toxic megacolon, gastric retention, hypersensitivity to any ingredients in SUPREP Bowel Prep Kit. WARNINGS AND PRECAUTIONS: Risk of fluid and electrolyte abnormalities: Encourage adequate hydration, assess concurrent medications, and consider laboratory assessments prior to and after each use; Cardiac arrhythmias: Consider pre-dose and post-colonoscopy ECGs in patients at increased risk; Seizures: Use caution in patients with a history of seizures and patients at increased risk of seizures, including medications that lower the seizure threshold; Patients with renal impairment or taking medications that affect renal functions: Use caution, ensure adequate hydration and consider laboratory testing; Suspected GI obstruction or perforation: Rule out the diagnosis before administration; Patients at risk for aspiration: Observe during administration. ADVERSE REACTIONS: Most common adverse reactions: Adults: (> 2%) are overall discomfort, abdominal distention, abdominal pain, nausea, and vomiting; Pediatric Patients (>10%) are nausea, abdominal pain, abdominal bloating and vomiting. DRUG INTERACTIONS: Drugs that may increase the risk of fluid and electrolyte abnormalities.