Please visit Salix.com to obtain additional $100 off coupons for up to 5 future refills.
RXBIN# IDENTIFICATION# PERSON CODE# EXPIRES
610575 CLSA7343204 001 07/31/08
Product dispensed is pursuant to terms of coupon. Not valid in MA. VOID where prohibited by law. This offer is not valid for prescriptions reimbursed in whole or in part by Medicaid, Medicare, Federal, or state funded programs. Not valid if reproduced or submitted to other payor. It is illegal for any person to sell, purchase, or trade this coupon.
Pharmacist, please give this coupon to the patient to activate the coupon for additional 5 uses.
To the Patient: You must present this card to the pharmacist along with your prescription to participate in this program. Should you have any questions regarding your eligibility or benefits or if you wish to discontinue your participation, call the Colazal Pharmacy Card program at 866-669-7597 (8:00 am - 8:00 pm EST, Mon-Fri.). If your pharmacy is unable to process this coupon, please mail a copy of this card with your pharmacy receipt indicating your purchase of Colazal and the amount paid to: Colazal Pharmacy Card program, PO Box 42255, Cincinnati, OH 45242-9733.
To the Pharmacist: This card is part of a Salix Pharmaceuticals loyalty program for COLAZAL® 750 mg capsules.
  • This coupon is valid for reimbursement at retail pharmacies only.
  • Transmit claims online to Wellpoint NextRx.
  • Wellpoint NextRx requires valid prescriber DEA# or NPI#, Patient Name, and Person Code for claim adjudication.
  • This coupon must be accompanied by a prescription. No substitutions permitted.
  • This coupon is good for up to $100 off the co-payment of, or cash price paid for, a 30 day supply of COLAZAL 750 mg capsules NDC #65649-101-02 or NDC #65649-101-50.
  • Process claim using COB fields, with a code type of 08.
  • For assistance filing this claim, please call the Wellpoint NextRx Help Desk, 1-866-291-1621.
  • Program may be cancelled at anytime without notice. Void where prohibited by law.
COL 01/08 PRINTED IN USA, © COPYRIGHT 2008, COLAZAL® is a registered trademark of Salix Pharmaceuticals, ALL RIGHTS RESERVED. VOID WHERE PROHIBITED BY LAW.