Save on Bensal HP

How to Redeem the Patient Access Card:

  1. Download and print your savings card by clicking on the button below:
  2. When you fill your Rx, show this savings card to the pharmacist and receive your instant discount. Ask the pharmacist to process your insurance first and this rebate second.
  3. Keep this savings card with you for future refills. The card is valid for 12 uses.

*All eligible patients receive savings. Please see eligibility terms below or click here to download the PDF.

Eligibility Terms:

  • 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. This offer is not valid in Massachusetts or Minnesota or where otherwise prohibited, taxed or otherwise restricted.
  • Offer good only in the USA at participating retail pharmacies and cannot be redeemed at government-subsidized clinics.
  • This coupon may be used up to 12 times.
  • EPI Health reserves the right to rescind, revoke or amend this offer without notice.
  • The selling, purchasing, trading or counterfeiting of this coupon is prohibited by law.
  • Offer may not be combined with any other rebate, coupon, free trial, or similar offer. Coupon has no cash value. No cash back.
  • Patients understand and agree to comply with the terms and conditions of this offer as set forth here.

To the Pharmacist:

SimpleSaveRx has been authorized to reimburse you up to a maximum benefit, for processing this coupon when accompanied by a prescription for branded BensalHP, Sitavig, Nuvail, Bionect, Inova or Umecta. For Insured Patients: this card will cover the difference between the patient’s co-pay and up to the program maximum, which is subject to change. Any additional amounts due are the responsibility of the patient. For Cash Patients: this card will decrease the patient’s out-of-pocket cost.

This claim may be submitted one of the following three ways:

  1. This claim may be submitted electronically through SimpleSaveRx. Submit all claims in NCPDP standard D.O. Secondary processing should follow NCPDP standards for Co-pay Only billing using group code X10200 and Other Coverage Code 8 (OCC8), if the patients primary insurance does not cover the brand please resubmit using group code X10200 and Other Coverage Code 3 (OCC3). If you have any questions regarding electronic submission, please call the pharmacy processing help desk at 1-844-728-3479 (844-SAVE4RX).
  2. 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:
    SimpleSaveRx 3350 N Arizona Ave., Suite 2, Chandler, AZ 85225.
  3. 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 a duplicate pharmacy label or pharmacy receipt which must include the following information: drug name, the drug quantity, the prescription number, the fill date, the name and address of the pharmacy, the prescribing physician, the patient’s name, and the co-pay amount paid. In addition to this information, please instruct the patient to include the patient’s return address and to mail this information to SimpleSaveRx, 3350 N Arizona Ave., Suite 2, Chandler, AZ 85225, for prompt payment. For expedited processing, fax voucher and Rx receipt to: 480-444-1449. Please retain a copy of the coupon and file with each prescription for auditing purposes and return the original to the patient.