Please complete the form below to receive your patient savings voucher for up to $15 after paying the first $40 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 of your remaining out-of-pocket expenses, up to a maximum of $15 after paying the first $40 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 1-866-933-8326.
To Pharmacist: For PRIMARY claims, submit a PRIMARY claim to Argus under BIN: 600428/PCN: 06780000. For SECONDARY claims, process a Coordination of Benefits (COB/split bill) claim using the patient's prescription insurance for the PRIMARY claim. Submit the SECONDARY claim to Argus under BIN: 600428/PCN: 06780000.
For pharmacy processing questions, please call 1-866-933-8326.
Eligibility Criteria: This coupon is not valid for prescriptions reimbursed under Medicare, Medicaid, or any other federal or state program, or where prohibited by law. Offer valid only for prescriptions filled in the United States. Braintree Laboratories, Inc. reserves the right to discontinue this offer at any time. It is a violation of federal law to buy, sell, or counterfeit this certificate. Offer expires December 31, 2020.
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. Most common adverse reactions (>2%) are overall discomfort, abdominal distention, abdominal pain, nausea, vomiting and headache.
Use is contraindicated in the following conditions: gastrointestinal (GI) obstruction, bowel perforation, toxic colitis and toxic megacolon, gastric retention, ileus, known allergies to components of the kit. Use caution when prescribing for patients with a history of seizures, arrhythmias, impaired gag reflex, regurgitation or aspiration, severe active ulcerative colitis, impaired renal function or patients taking medications that may affect renal function or electrolytes. Use can cause temporary elevations in uric acid. Uric acid fluctuations in patients with gout may precipitate an acute flare. Administration of osmotic laxative products may produce mucosal aphthous ulcerations, and there have been reports of more serious cases of ischemic colitis requiring hospitalization. Patients with impaired water handling who experience severe vomiting should be closely monitored including measurement of electrolytes. Advise all patients to hydrate adequately before, during, and after use. Each bottle must be diluted with water to a final volume of 16 ounces and ingestion of additional water as recommended is important to patient tolerance.