COMMERCIALLY INSURED DRUG COVERED

WHEN DEDUCTIBLE IS MET

MOST ELIGIBLE COMMERCIALLY INSURED PATIENTS WILL PAY AS LITTLE AS A

25copay

*Terms and Conditions apply. See table below for pricing and maximum number of fills allowed.

COMMERCIALLY INSURED DRUG NOT 
COVERED†
 

MOST ELIGIBLE COMMERCIALLY INSURED PATIENTS, WHEN DRUG IS NOT COVERED,
WILL PAY AS LITTLE AS A

*Terms and Conditions apply. See table below for pricing and maximum number of fills allowed.

COMMERCIALLY INSURED DRUG NOT 
COVERED†
 

MOST ELIGIBLE COMMERCIALLY INSURED PATIENTS, WHEN DRUG IS NOT COVERED,
WILL PAY AS LITTLE AS A

25Copay

*Terms and Conditions apply. See table below for pricing and maximum number of fills allowed.

If your deductible co-pay is too high, or if you are uninsured
ask your pharmacist for the $75†† cash pay option§.
Not available for all products¶¶
*If prior authorization is approved, patient will pay the covered amount listed below. After the indicated number of fills,
patient will pay the uninsured amount for any remaining fills available. Please see below for terms and conditions.
†Insured not covered is defined as a patient who has commercial insurance but the drug is not covered on the plan’s formulary or has an NDC block, prior authorization, step edit or other restriction that has not been met.
†† Prices may vary for different product sizes.
§ Not available for Medicare/Medicaid patients.
¶¶  Not available for all products.

SAVINGS FOR ELIGIBLE PATIENTS

Product Name Size Covered
Co-Pay		 Covered
Fills		 Not Covered
Co-Pay		 Cash
Co-Pay		 Not Covered
& Cash
Fills§
ARAZLO® (tazarotene) Lotion. 0.045% 45 g $25 6 $65 $75 6
BRYHALI® (halobetasol) Lotion, 0.01% 60 g $25 6 $65 $75 6
CABTREO™ (clindamycin phosphate, adapalene and benzoyl peroxide) Topical Gel 1.2%/0.15%/3.1% 50 g $0 6 $75 N/A 6
DUOBRII® (halobetasol propionate and tazarotene) Lotion, 0.01%/0.045% 100 g $25 6 $65 $75 6
JUBLIA®(efinaconazole) Topical Solution 10% 4 mL
8 mL		 $0 12 $65
$130		 $75
$150		 12
LUZU® (luliconazole) Cream, 1% 60 g $25 6 N/A N/A N/A
NORITATE® (metronidazole) Cream, 1% 60 g $25 6 N/A N/A N/A
ONEXTON® (clindamycin phosphate and benzoyl peroxide) Gel, 1.2% / 3.75% 50 g $25 6 $65 $75 2
RETIN-A MICRO® (tretinoin) Gel Microsphere 0.08% / 0.06% 50 g $25 6 $65 $75 2
XERESE® (acyclovir and hydrocortisone) cream 5%/1% 5 g $25 6 $65 $75 N/A
ARAZLO® (tazarotene) Lotion. 0.045%
Size 45 g
Covered Co-Pay $25
Covered Fills 6
Not Covered
Co-Pay		 $65
Cash Co-Pay $75
Not Covered & Cash Fills§ 6
BRYHALI® (halobetasol) Lotion, 0.01%
Size 60 g
Covered Co-Pay $25
Covered Fills 6
Not Covered
Co-Pay		 $65
Cash Co-Pay $75
Not Covered & Cash Fills§ 6
CABTREO™ (clindamycin phosphate, adapalene and benzoyl peroxide) Topical Gel 1.2%/0.15%/3.1%
Size 50 g
Covered Co-Pay $0
Covered Fills 6
Not Covered
Co-Pay		 $75
Cash Co-Pay N/A
Not Covered & Cash Fills§ 6
DUOBRII®(halobetasol propionate and tazarotene) Lotion, 0.01%/0.045%
Size 100 g
Covered Co-Pay $25
Covered Fills 6
Not Covered
Co-Pay		 $65
Cash Co-Pay $75
Not Covered & Cash Fills§ 6
JUBLIA®(efinaconazole) Topical Solution 10%
Size 4 mL/8 mL
Covered Co-Pay $0
Covered Fills 12
Not Covered
Co-Pay		 $65
$130
Cash Co-Pay $75
$150
Not Covered & Cash Fills§ 12
LUZU®(luliconazole) Cream, 1%
Size 60 g
Covered Co-Pay $25
Drug Covered Fills 6
Not Covered
Co-Pay		 N/A
Cash Co-Pay N/A
Not Covered & Cash Fills§ N/A
NORITATE®(metronidazole) Cream, 1%
Size 60 g
Covered Co-Pay $25
Drug Covered Fills 6
Not Covered
Co-Pay		 N/A
Cash Co-Pay N/A
Not Covered & Cash Fills§ N/A
ONEXTON®(clindamycin phosphate and benzoyl peroxide) Gel, 1.2% / 3.75%
Size 50 g
Covered Co-Pay $25
Covered Fills 6
Not Covered
Co-Pay		 $65
Cash Co-Pay $75
Not Covered & Cash Fills§ 2
RETIN-A MICRO®(tretinoin) Gel Microsphere 0.08% / 0.06%
Size 50 g
Covered Co-Pay $25
Covered Fills 6
Not Covered
Co-Pay		 $65
Cash Co-Pay $75
Not Covered & Cash Fills§ 2
XERESE®(acyclovir and hydrocortisone) cream 5%/1%
Size 5 g
Covered Co-Pay $25
Covered Fills 6
Not Covered
Co-Pay		 $65
Cash Co-Pay $75
Not Covered & Cash Fills§ N/A
§After the indicated number of fills, patient will pay uninsured amount for any remaining fills available.
*If prior authorization is approved, patient will pay the covered amount listed below. After the indicated number of fills, patient will pay the uninsured amount for any remaining fills available. Please see below for terms and conditions.
Eligibility Criteria/Terms and Conditions for Ortho Dermatologics Access Coupon:

By using the Ortho Dermatologics Access coupon, you confirm that you understand and agree to comply with the following terms and conditions of this offer:

  • This offer is only valid for patients with commercial insurance and uninsured cash-pay patients on applicable products as shown on the chart above.
  • This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.
  • You agree not to seek reimbursement for all or any part of the benefit received through this offer and are responsible for making any required reports of your use of this offer to any insurer or other third party who pays any part of the prescription filled.
  • This offer is good only in the United States of America (including the District of Columbia, Puerto Rico and the U.S. Virgin Islands) at retail pharmacies owned and operated by Walgreen Co. (or its affiliates) and other participating independent retail pharmacies. This offer is not valid in Massachusetts or Minnesota or where otherwise prohibited, taxed, or otherwise restricted. This offer is not valid for redemption in the State of California or by any resident of the State of California with regard to any product for which a therapeutically equivalent generic product is available.
  • This offer is not valid for any person that is 65 years of age or older without commercial insurance. You must be 18 years of age or older to redeem this offer for yourself or a minor.
  • You must present this coupon along with your prescription to participate in this program. You must activate this coupon before using by calling 1-855-202-3279, or by visiting
    https://ortho-dermatologics.copaysavingsprogram.com/.
  • This coupon is good for use only with the products identified herein.
  • No other purchase is necessary.
  • This offer cannot be redeemed at government-subsidized clinics.
  • This coupon is good for a limited number of fills only. For a complete listing of the maximum number of fills for each product for which this offer applies, please review the program terms and conditions, which are posted at http://www.orthorxaccess.com.
  • Reimbursement limitations apply, and may vary based on your insurance coverage. Patient is responsible for all additional costs and expenses after reimbursement limits are reached.
  • This coupon and offer are not health insurance.
  • The selling, purchasing, trading, or counterfeiting of this coupon is prohibited by law. Void if reproduced.
  • This offer is not valid with other offers. This coupon has no cash value. No cash back.
  • Ortho Dermatologics' affiliated entities reserve the right to rescind, revoke, terminate, or amend this offer at any time, without notice.
  • You understand and agree to comply with the terms and conditions of this offer as set forth above and at http://www.orthorxaccess.com.
  • For questions call: 1-855-202-3279.