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Fill Out Your Vyvanse Coupon Form

The Vyvanse Coupon form serves as a valuable tool for individuals seeking financial assistance with their Vyvanse prescriptions. By filling out this form, patients can access discounts that can significantly lower their out-of-pocket expenses. Take the first step towards savings by completing the form below.

Launch Vyvanse Coupon Editor Now

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Article Structure

The Vyvanse Coupon form is an essential tool for patients seeking to manage their medication costs effectively. Designed for use with three different plans—Patient Choice, Therapy First, and Therapy First Plus—it provides detailed instructions on how to file insurance claims related to Vyvanse prescriptions. This form captures all the necessary billing information, from patient identification to claim specifics, ensuring a smooth transaction process. Each plan has unique identifiers, such as BIN and PCN numbers, which are crucial for proper processing. Furthermore, the form indicates mandatory and optional fields to guide users on which information is necessary for successful claim submissions. Beyond billing, it also addresses various rejected claims and essential follow-up actions. Whether you're a pharmacy professional managing claims or a patient aiming to utilize your benefits, understanding and completing the Vyvanse Coupon form accurately can significantly impact your healthcare experience.

Vyvanse Coupon Example

Emdeon

PATIENT CHOICE / THERAPY FIRST / THERAPY FIRST PLUS

NCPDP vD.0 Payer Sheet

Claim Billing / Claim Re-bill

GENERAL INFORMATION

Payer Name: Patient Choice / Therapy First / Therapy First	Date: 10/17/2011
Plus
Plan Name/Group Name: Patient Choice	BIN: 004682	PCN: CN
Plan Name/Group Name: Therapy First	BIN: 004682	PCN: CN
Plan Name/Group Name: Therapy First Plus	BIN: 004682	PCN: CN
Processor: Emdeon
Effective as of: 11/17/2011	NCPDP Telecommunication Standard Version/Release #: D.0

NCPDP Data Dictionary Version Date: 9/2010	NCPDP External Code List Version Date: 9/2010

Contact/Information Source: 800-422-5604

Pharmacy Help Desk Info: 800-422-5604

Other versions supported: 5.1 Telecommunication Standard Supported until 12/31/2011. Refer to the 5.1 payer sheet.

OTHER TRANSACTIONS SUPPORTED

Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

Transaction Code	Transaction Name
B1	Billing Transaction
B2	Reversal Transaction
B3	Re-Bill Transaction

FIELD LEGEND FOR COLUMNS

Payer Usage	Value	Explanation	Payer
Column			Situation
			Column
MANDATORY	M	The Field is mandatory for the Segment in	No
		the designated Transaction.

REQUIRED	R	The Field has been designated with the	No
		situation of "Required" for the Segment in the
		designated Transaction.
QUALIFIED	RW	“Required when”. The situations designated	Yes
REQUIREMENT		have qualifications for usage ("Required if x",
		"Not required if y").

Fields that are not used in the Claim Billing/Claim Re-bill transactions and those that do not have qualified requirements (i.e. not used) for this payer are excluded from the template.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

CLAIM BILLING/CLAIM RE-BILL TRANSACTION

The following lists the segments and fields in a Claim Billing or Claim Re-bill Transaction for the NCPDP Telecommunication Standard Implementation Guide Version D.Ø.

Transaction Header Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X

		Transaction Header Segment				Claim Billing/Claim Re-bill
Field #		NCPDP Field Name	Value		Payer	Payer Situation
					Usage
	1Ø1-A1	BIN NUMBER	004682		M
	1Ø2-A2	VERSION/RELEASE NUMBER	DØ		M
	1Ø3-A3	TRANSACTION CODE	B1 OR B3		M
	1Ø4-A4	PROCESSOR CONTROL NUMBER	CN		M
	1Ø9-A9	TRANSACTION COUNT	1		M
	2Ø2-B2	SERVICE PROVIDER ID QUALIFIER	01 – NPI		M
	2Ø1-B1	SERVICE PROVIDER ID	NPI		M
	4Ø1-D1	DATE OF SERVICE			M
	11Ø-AK	SOFTWARE	ALL SPACES		M
		VENDOR/CERTIFICATION ID

Insurance Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X

		Insurance Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø4”
Field #		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	3Ø2-C2	CARDHOLDER ID			M
	3Ø1-C1	GROUP ID			R	Imp Guide: Required if necessary for
						state/federal/regulatory agency programs.
						Required if needed for pharmacy claim
						processing and payment.

Patient Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X
This Segment is situational

		Patient Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø1”
Field		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	3Ø4-C4	DATE OF BIRTH			R
	3Ø5-C5	PATIENT GENDER CODE			R
	31Ø-CA	PATIENT FIRST NAME			R	Imp Guide: Required when the patient has
						a first name.
	311-CB	PATIENT LAST NAME			R
	322-CM	PATIENT STREET ADDRESS			RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Patient Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø1”
Field		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	323-CN		PATIENT CITY ADDRESS		RW	Imp Guide: Optional.
						Payer Requirement : Required when
						available.
	324-CO		PATIENT STATE /		RW	Imp Guide: Optional.
			PROVINCE ADDRESS
						Payer Requirement : Required when
						available.
	325-CP		PATIENT ZIP / POSTAL ZONE		RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.
	326-CQ		PATIENT PHONE NUMBER		RW	Imp Guide: Optional.
						Payer Requirement: Required when
						available.
	35Ø-HN		PATIENT E-MAIL ADDRESS		RW	Imp Guide: May be submitted for the
						receiver to relay patient health care
						communications via the Internet when
						provided by the patient.
						Payer Requirement: Required when
						available.

Claim Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X
This payer supports partial fills
This payer does not support partial fills			X

		Claim Segment					Claim Billing/Claim Re-bill
		Segment Identification (111-AM) =
		“Ø7”
Field #		NCPDP Field Name	Value		Payer		Payer Situation
					Usage
	455-EM	PRESCRIPTION/SERVICE	1 = Rx Billing		M		Imp Guide: For Transaction Code of
		REFERENCE NUMBER QUALIFIER					“B1”, in the Claim Segment, the
							Prescription/Service Reference Number
							Qualifier (455-EM) is “1” (Rx Billing).
	4Ø2-D2	PRESCRIPTION/SERVICE	up to 12 positions		M
		REFERENCE NUMBER
	436-E1	PRODUCT/SERVICE ID QUALIFIER	03 - NDC		M		00 if Compound Code (406-D6) = 2
	4Ø7-D7	PRODUCT/SERVICE ID	11 digit NDC		M		0 if Compound Code (406-D6) = 2
	442-E7	QUANTITY DISPENSED	Format 9(7)V999		R

	4Ø3-D3	FILL NUMBER	New = 00 (zeros must be		R
			sent)
	4Ø5-D5	DAYS SUPPLY			R
	4Ø6-D6	COMPOUND CODE	1 = Not a Compound		R	Refer to Compound Segment when
			2 = Compound			Compound Code (406-D6) = 2
	4Ø8-D8	DISPENSE AS WRITTEN			R
		(DAW)/PRODUCT SELECTION CODE
	414-DE	DATE PRESCRIPTION WRITTEN			R
	415-DF	NUMBER OF REFILLS AUTHORIZED			R	Imp Guide: Required if necessary for plan
						benefit administration.
		“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Claim Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø7”
Field #			NCPDP Field Name	Value	Payer		Payer Situation
					Usage
	419-DJ	PRESCRIPTION ORIGIN CODE			R	Imp Guide: Required if necessary for plan
						benefit administration.
	354-NX	SUBMISSION CLARIFICATION CODE		Maximum count of 3.	RW	Imp Guide: Required if Submission
		COUNT				Clarification Code (42Ø-DK) is used.
						Payer Requirement: Same as Imp Guide
	42Ø-DK	SUBMISSION CLARIFICATION CODE			RW	Imp Guide: Required if clarification is
						needed and value submitted is greater
						than zero (Ø).
						If the Date of Service (4Ø1-D1) contains
						the subsequent payer coverage date, the
						Submission Clarification Code (42Ø-DK)
						is required with value of “19” (Split Billing
						– indicates the quantity dispensed is the
						remainder billed to a subsequent payer
						when Medicare Part A expires. Used only
						in long-term care settings) for individual
						unit of use medications.
						Payer Requirement: Same as Imp Guide
	3Ø8-C8	OTHER COVERAGE CODE		0 = Not specified by patient	RW	Imp Guide: Required if needed by
				1 = No other coverage		receiver, to communicate a summation of
				3 = Other coverage exist –		other coverage information that has been
				claim not covered*		collected from other payers.
				8 = Claim is billing for patient
				financial responsibility		Required for Coordination of Benefits.
				only*
						Payer Requirement: Same as Imp Guide.
						*requires COB segment to be sent.
	461-EU	PRIOR AUTHORIZATION TYPE CODE		1 = Prior Authorization, if	RW	Imp Guide: Required if this field could
				applicable		result in different coverage, pricing, or
						patient financial responsibility.
						Payer Requirement: Same as Imp Guide
	462-EV	PRIOR AUTHORIZATION NUMBER		If applicable to Rx	RW	Imp Guide: Required if this field could
		SUBMITTED				result in different coverage, pricing, or
						patient financial responsibility.
						Payer Requirement: Same As Imp Guide
	995-E2	ROUTE OF ADMINISTRATION			RW	Imp Guide: Required if specified in trading
						partner agreement.
						Payer Requirement: When compound
						code (406-D6) = 2

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Pricing Segment Questions			Check	Claim Billing/Claim Re-bill
				If Situational, Payer Situation
This Segment is always sent			X

		Pricing Segment				Claim Billing/Claim Re-bill

		Segment Identification (111-AM) =
		“11”
Field #		NCPDP Field Name	Value		Payer	Payer Situation
					Usage
	4Ø9-D9	INGREDIENT COST SUBMITTED			R
	412-DC	DISPENSING FEE SUBMITTED			R	Imp Guide: Required if its value has an
						effect on the Gross Amount Due (43Ø-
						DU) calculation.
	433-DX	PATIENT PAID AMOUNT SUBMITTED			R	Imp Guide: Required if this field could
						result in different coverage, pricing, or
						patient financial responsibility.
	438-E3	INCENTIVE AMOUNT SUBMITTED			RW	Imp Guide: Required if its value has an
						effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide
	478-H7	OTHER AMOUNT CLAIMED	Maximum count of 3.		RW	Imp Guide: Required if Other Amount
		SUBMITTED COUNT				Claimed Submitted Qualifier (479-H8) is
						used.
						Payer Requirement: Same as Imp Guide
	479-H8	OTHER AMOUNT CLAIMED			RW	Imp Guide: Required if Other Amount
		SUBMITTED QUALIFIER				Claimed Submitted (48Ø-H9) is used.
						Payer Requirement: Same as Imp Guide
	48Ø-H9	OTHER AMOUNT CLAIMED			RW	Imp Guide: Required if its value has an
		SUBMITTED				effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide
	481-HA	FLAT SALES TAX AMOUNT			RW	Imp Guide: Required if its value has an
		SUBMITTED				effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.
	482-GE	PERCENTAGE SALES TAX AMOUNT			RW	Imp Guide: Required if its value has an
		SUBMITTED				effect on the Gross Amount Due (43Ø-
						DU) calculation.
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.
	483-HE	PERCENTAGE SALES TAX RATE			RW	Imp Guide: Required if Percentage Sales
		SUBMITTED				Tax Amount Submitted (482-GE) and
						Percentage Sales Tax Basis Submitted
						(484-JE) are used.
						Required if this field could result in
						different pricing.
						Required if needed to calculate
						Percentage Sales Tax Amount Paid (559-
						AX).
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Pricing Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“11”
Field #		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	484-JE	PERCENTAGE SALES TAX BASIS			RW	Imp Guide: Required if Percentage Sales
		SUBMITTED				Tax Amount Submitted (482-GE) and
						Percentage Sales Tax Rate Submitted
						(483-HE) are used.
						Required if this field could result in
						different pricing.
						Required if needed to calculate
						Percentage Sales Tax Amount Paid (559-
						AX).
						Payer Requirement: Same as Imp Guide.
						If Sales Tax applies to State.
	426-DQ	USUAL AND CUSTOMARY CHARGE			R	Imp Guide: Required if needed per trading
						partner agreement.
	43Ø-DU	GROSS AMOUNT DUE			R
	423-DN	BASIS OF COST DETERMINATION			R	Imp Guide: Required if needed for
						receiver claim/encounter adjudication.

Prescriber Segment Questions				Check	Claim Billing/Claim Re-bill
					If Situational, Payer Situation
					If Situational, Payer Situation
This Segment is always sent				X
This Segment is situational

			Prescriber Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø3”
Field #		NCPDP Field Name		Value		Payer	Payer Situation
						Usage
	466-EZ	PRESCRIBER ID QUALIFIER		01 – NPI		R	Imp Guide: Required if Prescriber ID (411-
				12 - DEA			DB) is used.
	411-DB	PRESCRIBER ID		NPI or DEA		R	Imp Guide: Required if this field could
							result in different coverage or patient
							financial responsibility.
							Required if necessary for
							state/federal/regulatory agency programs.
	427-DR	PRESCRIBER LAST NAME				RW	Imp Guide: Required when the Prescriber
							ID (411-DB) is not known.
							Required if needed for Prescriber ID (411-
							DB) validation/clarification.
							Payer Requirement: Required when
							submitting DEA
	364-2J	PRESCRIBER FIRST NAME				RW	Imp Guide: Required if needed to assist in
							identifying the prescriber.
							Required if necessary for
							state/federal/regulatory agency programs.
							Payer Requirement: Required when
							submitting DEA

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			Prescriber Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø3”
Field #		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	365-2K	PRESCRIBER STREET ADDRESS			RW	Imp Guide: Required if needed to assist in
						identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA
	366-2M	PRESCRIBER CITY ADDRESS			RW	Imp Guide: Required if needed to assist in
						identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA
	367-2N	PRESCRIBER STATE/PROVINCE			RW	Imp Guide: Required if needed to assist in
		ADDRESS				identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA
	368-2P	PRESCRIBER ZIP/POSTAL ZONE			RW	Imp Guide: Required if needed to assist in
						identifying the prescriber.
						Required if necessary for
						state/federal/regulatory agency programs.
						Payer Requirement: Required when
						submitting DEA

Coordination of Benefits/Other Payments			Check	Claim Billing/Claim Re-bill
Segment Questions				If Situational, Payer Situation
This Segment is always sent
This Segment is situational			X	Required	only for secondary, tertiary, etc claims.			Other	Coverage
				Code (308-C8) = 3 or 8.

Scenario 2 - Other Payer-Patient Responsibility			X	Required	only for secondary, tertiary, etc claims.			Other	Coverage
Amount Repetitions and Benefit Stage Repetitions				Code (308-C8) = 3 or 8.
Only

		Coordination of Benefits/Other					Claim Billing/Claim Re-bill
		Payments Segment
		Segment Identification (111-AM) =					Scenario 2- Other Payer-Patient
		“Ø5”					Responsibility Amount Repetitions and
							Benefit Stage Repetitions Only
Field #		NCPDP Field Name	Value			Payer	Payer Situation
						Usage
	337-4C	COORDINATION OF	Maximum count of 9.			M
		BENEFITS/OTHER PAYMENTS
		COUNT
	338-5C	OTHER PAYER COVERAGE TYPE				M
	339-6C	OTHER PAYER ID QUALIFIER	03 - BIN			R	Imp Guide: Required if Other Payer ID
							(34Ø-7C) is used.
		“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Coordination of Benefits/Other

Claim Billing/Claim Re-bill

Payments Segment

Segment Identification (111-AM) =

Scenario 2- Other Payer-Patient

“Ø5”

Responsibility Amount Repetitions and

Benefit Stage Repetitions Only

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

34Ø-7C

OTHER PAYER ID

BIN

Imp Guide: Required if identification of the

Other Payer is necessary for

claim/encounter adjudication.

471-5E

OTHER PAYER REJECT COUNT

Maximum count of 5.

Imp Guide: Required if Other Payer Reject

Code (472-6E) is used.

Payer Requirement: Same as Imp Guide

472-6E

OTHER PAYER REJECT CODE

Imp Guide: Required when the other

payer has denied the payment for the

billing, designated with Other Coverage

Code (3Ø8-C8) = 3 (Other Coverage

Billed – claim not covered).

Payer Requirement: Same as Imp Guide

353-NR

OTHER PAYER-PATIENT

Maximum count of 25.

Imp Guide: Required if Other Payer-

RESPONSIBILITY AMOUNT COUNT

Patient Responsibility Amount Qualifier

(351-NP) is used.

Payer Requirement: Same as Imp Guide

351-NP

OTHER PAYER-PATIENT

Imp Guide: Required if Other Payer-

RESPONSIBILITY AMOUNT

Patient Responsibility Amount (352-NQ) is

QUALIFIER

used.

Payer Requirement: Same as Imp Guide

352-NQ

OTHER PAYER-PATIENT

Imp Guide: Required if necessary for

RESPONSIBILITY AMOUNT

patient financial responsibility only billing.

Required if necessary for

state/federal/regulatory agency programs.

Not used for non-governmental agency

programs if Other Payer Amount Paid

(431-DV) is submitted.

Payer Requirement: Same as Imp Guide

DUR/PPS Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

for use to define professional service or override clinical edits

DUR/PPS Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“Ø8”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

473-7E

DUR/PPS CODE COUNTER

Maximum of 9 occurrences.

Imp Guide: Required if DUR/PPS

Segment is used.

“Materials Reproduced With the Consent of

©National Council for Prescription Drug Programs, Inc.

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

			DUR/PPS Segment				Claim Billing/Claim Re-bill
			Segment Identification (111-AM) =
			Segment Identification (111-AM) =
			“Ø8”
Field #		NCPDP Field Name		Value	Payer		Payer Situation
					Usage
	439-E4	REASON FOR SERVICE CODE			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	44Ø-E5	PROFESSIONAL SERVICE CODE			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	441-E6	RESULT OF SERVICE CODE			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	474-8E	DUR/PPS LEVEL OF EFFORT			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.
	475-J9	DUR CO-AGENT ID QUALIFIER			R	Imp Guide: Required if DUR Co-Agent ID
						(476-H6) is used.
	476-H6	DUR CO-AGENT ID			R	Imp Guide: Required if this field could
						result in different coverage, pricing,
						patient financial responsibility, and/or drug
						utilization review outcome.
						Required if this field affects payment for or
						documentation of professional pharmacy
						service.

Compound Segment Questions

Check

Claim Billing/Claim Re-bill

If Situational, Payer Situation

This Segment is always sent

This Segment is situational

required when Compound Code (406-D6) = 2

Compound Segment

Claim Billing/Claim Re-bill

Segment Identification (111-AM) =

“1Ø”

Field #

NCPDP Field Name

Value

Payer

Payer Situation

Usage

45Ø-EF

COMPOUND DOSAGE FORM

DESCRIPTION CODE

451-EG

COMPOUND DISPENSING UNIT

FORM INDICATOR

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

447-EC	COMPOUND INGREDIENT	Maximum 25 ingredients	M
	COMPONENT COUNT
488-RE	COMPOUND PRODUCT ID	03 - NDC	M
	QUALIFIER
489-TE	COMPOUND PRODUCT ID	11 digit NDC	M
448-ED	COMPOUND INGREDIENT QUANTITY		M
449-EE	COMPOUND INGREDIENT DRUG		R	Imp Guide: Required if needed for
	COST			receiver claim determination when
				multiple products are billed.
49Ø-UE	COMPOUND INGREDIENT BASIS OF		R	Imp Guide: Required if needed for
	COST DETERMINATION			receiver claim determination when
				multiple products are billed.

	End of Request Claim Billing/Claim Re-bill (B1/B3) Payer Sheet Template

“Materials Reproduced With the Consent of

2Ø1Ø NCPDP”

Patient Choice & Therapy First & Therapy First Plus D.0 Claim Billing And Response Payer Sheet 20111017.Docx

Get Vyvanse Coupon PDF Form

Form Characteristics

Fact Name	Description
Payer Information	The coupon form is designed for three specific programs: Patient Choice, Therapy First, and Therapy First Plus. Each program shares the same BIN and PCN codes.
Contact Information	The form lists a contact number (800-422-5604) for both participant inquiries and pharmacy help desk assistance.
Transaction Codes	Supported transactions include billing (B1), reversals (B2), and re-bills (B3). Each transaction has specific segment and field requirements.
Form Versions	The form uses the NCPDP Telecommunication Standard Version D.0, effective from November 17, 2011, and is supported until December 31, 2011.

Guidelines on Utilizing Vyvanse Coupon

Completing the Vyvanse Coupon form involves several straightforward steps that ensure accurate information is provided. By following the instructions carefully, you can efficiently fill out the necessary sections of the form to process your claim. Here’s what to do:

Gather Necessary Information: Collect all required personal information, including your insurance details and identification numbers.
Fill in General Information: Enter the payer name, which could be "Patient Choice," "Therapy First," or "Therapy First Plus." Also, include the date, BIN number (004682), and processor control number (CN).
Complete the Patient Segment: Include the patient's name (first and last), date of birth, gender, and address. Ensure you have the patient’s email and phone number handy, as these may be required.
Input Claim Details: In this section, provide the transaction code (B1 or B3), prescription reference number, etc. Make sure to include any associated costs accurately in the pricing segment.
Review Each Section: Go through the entire form to confirm that all information is complete and correct. Missing or incorrect data can delay processing.
Submit the Form: Once you're confident everything is accurate, submit the form as instructed, whether via online portal or mailing it directly to the processing entity.

What You Should Know About This Form

What is a Vyvanse coupon form?

A Vyvanse coupon form is a document that allows patients to receive discounts or savings on their prescription for Vyvanse. These coupons are typically provided by the manufacturer or pharmacy benefits programs and can help lower out-of-pocket costs, making the medication more affordable for users.

How does one obtain a Vyvanse coupon?

Vyvanse coupons can be obtained online from the manufacturer's website or participating pharmacies. Patients can also ask their healthcare providers if they have access to any current offers. Many health insurance plans may have specific requirements or limitations regarding coupon use. Therefore, it is wise to check these details before proceeding with redemption.

Can uninsured patients use a Vyvanse coupon?

Yes, uninsured patients can often use a Vyvanse coupon to receive discounts. These coupons are designed to provide financial relief regardless of insurance status. However, patients should always confirm with the pharmacy that they will accept the coupon before making a purchase.

Do Vyvanse coupons expire?

Most Vyvanse coupons have an expiration date clearly printed on them. Patients should pay attention to this date to ensure that they use the coupon before it becomes invalid. If the expiration date has passed, it is recommended to look for any new coupons or promotional offers that may be available.

Is there any limit to how many times a coupon can be used?

Often, the use of a Vyvanse coupon is limited to one per transaction or per prescription. Some coupons may only be used a certain number of times during a given year. The specific terms and conditions will be outlined on the coupon, so careful review is essential to avoid any misconceptions.

Can I use a Vyvanse coupon with my insurance?

In many cases, patients may be able to use a Vyvanse coupon alongside their insurance. However, certain insurance plans may have policies that limit this option. It is advisable to consult with both the pharmacy and the insurance provider to confirm whether combining a coupon with your insurance is feasible.

What information is required to use the Vyvanse coupon?

Using a Vyvanse coupon typically requires basic patient information, including the patient's name, prescription details, and possibly the cardholder ID associated with insurance plans when applicable. Each pharmacy may have slightly different requirements, so it’s wise to be prepared with all necessary information at the time of redemption.

What if my pharmacy does not accept the Vyvanse coupon?

If a pharmacy refuses to accept a Vyvanse coupon, patients should first inquire about the reason for the refusal. It might be due to specific pharmacy policies or insurance restrictions. If the problem persists, contacting the coupon’s provider or the manufacturer for assistance may be an advantageous step.

Are there any alternative savings options available for Vyvanse?

Yes, besides coupons, patients can explore patient assistance programs offered by the manufacturer, which may provide further discounts or access to free medication for those in financial need. Additionally, discussing alternative therapies or generic medications with a healthcare provider might also lead to substantial savings.

Common mistakes

Completing the Vyvanse coupon form can be a straightforward task, but small errors can lead to significant delays in processing or even rejection of claims. One of the most common mistakes is leaving out mandatory fields. Each section of the form has specific fields that must be filled out, such as the BIN number and the transaction code. Omitting these required fields results in processing issues, potentially leaving the patient without their medication.

Another frequent error is providing incorrect information in the patient section. It's vital to ensure that the patient’s full name, date of birth, and gender are filled out accurately. Inaccuracies can arise from simple typos or incorrect entries, leading to mismatches in the patient’s file. Such discrepancies may lead pharmacies to deny claims or require additional documentation, leading to delays.

Additionally, individuals often overlook the necessity of the patient's insurance details. Entering the correct group ID and cardholder ID is essential. Forgetting these can create confusion for pharmacies when verifying eligibility for discounts or benefits. In some cases, pharmacies may refuse to process the coupon due to missing insurance information.

Many people also fail to double-check the medication details outlined in the claim segment. Ensuring the correct prescription reference number and the proper National Drug Code (NDC) for Vyvanse is crucial. Entering an incorrect digit or an outdated code can lead to denied claims, significantly complicating the process for everyone involved.

Another overlooked aspect is the submission of supporting documents. If the form requests documentation like prior authorization, failing to include it can lead to rejection. Always review the requirements and submit any necessary paperwork alongside the form to ensure timely processing.

Picking the right transaction code is also a common stumbling block. Users may either mistakenly select the wrong code or misunderstand the codes’ meanings. Understanding whether to use B1 (billing) or B3 (re-bill) is essential for the proper processing of the claim. Selecting the incorrect code can trigger additional processing times as the pharmacy sorts through the error.

Furthermore, individuals often misinterpret the situational fields and neglect to provide relevant information. Certain fields may be marked as optional, yet they can be critical depending on the specific situation. If the payer requires a field that was marked as optional when additional coverage exists, it could lead to payment delays.

Reviewing the total amounts submitted is crucial. Mistakes in reporting the ingredient cost, dispensing fee, or patient-paid amount can lead to confusion and incorrect billing. Ensuring that all figures are accurate not only eases processing but assists in avoiding potential disputes with insurance providers.

Lastly, a common yet easily avoidable error is failing to sign or date the form where indicated. A missing signature may seem trivial, yet it can halt the processing entirely. Always complete the form thoroughly, paying attention to every detail, including signatures.

By avoiding these common mistakes, individuals can streamline the process of using Vyvanse coupons and access their medications more swiftly. A careful review of the completed form may make all the difference in ensuring a smooth transaction.

Documents used along the form

The Vyvanse Coupon form is often used in conjunction with other essential documents to ensure smooth processing of prescription claims. These forms help clarify billing procedures, patient information, and eligibility, among other critical aspects. Understanding these documents can enhance your experience when dealing with insurance matters related to Vyvanse.

Prescription Form: This document is filled out by the prescribing physician. It contains essential details such as the patient's name, medication dosage, frequency, and duration of treatment. A valid prescription is necessary for pharmacies to dispense Vyvanse.
Patient Insurance Card: The insurance card provides proof of coverage and helps the pharmacy verify the patient's insurance details. It typically displays the patient's ID number, group number, and other relevant information needed for billing and reimbursement.
Prior Authorization Request: This form may be required by the insurance company before the medication is covered. It documents the medical necessity of Vyvanse for treating the patient's condition and must be submitted by the prescribing physician or pharmacy.
Medication History Form: This document collects information about the patient's previous prescriptions and treatments. It aids healthcare providers and pharmacists in understanding the patient's medical history, ensuring safe and effective medication management.

Each of these documents plays a crucial role in ensuring a seamless process from prescription to coverage approval. Be sure to have them ready for quick reference when dealing with your Vyvanse prescription.

Similar forms

Health Insurance Claim Form (CMS-1500): Like the Vyvanse Coupon form, the CMS-1500 is used to submit claims for reimbursement of medical services. Both forms require detailed information about the patient, including identifiers such as names, addresses, and insurance details. Each must be filled out accurately to ensure proper processing and payment for medical treatments.
Prescription Drug Claim Form: This document serves a similar purpose to the Vyvanse Coupon form in that it allows patients to submit claims for prescription medications. Users must include the medication name, the prescribing physician's information, and patient insurance details, reflecting the same need for specificity as in the Vyvanse form.
Prior Authorization Request Form: Both this form and the Vyvanse Coupon form may require detailed patient information to obtain required approvals from insurance before medication can be dispensed. Accurate data must be shared, and both documents aim to facilitate important communication between healthcare providers and payers.
Pharmacy Benefit Manager (PBM) Claim Form: Much like the Vyvanse Coupon form, PBM claim forms are used when processing prescription drug claims through insurance. Each form requires similar information about the patient, the drug prescribed, and the provider, highlighting the necessity for precise record-keeping in medication management.

Dos and Don'ts

When filling out the Vyvanse Coupon form, it is crucial to ensure accuracy and completeness. Here are seven key actions to keep in mind:

Do double-check all information before submitting the form.
Don't leave any mandatory fields blank; ensure each required section is filled out completely.
Do include the correct BIN and PCN numbers as indicated on the payer sheet.
Don't use outdated versions of the form; always use the most recent version provided.
Do verify patient information, such as date of birth and contact details, to avoid processing delays.
Don't overlook optional fields that may require additional documentation; provide what can enhance the claim.
Do contact the pharmacy help desk if you have questions about how to complete any section.

Following these guidelines can improve the likelihood of a smooth and efficient processing of your Vyvanse Coupon form.

Misconceptions

Misconceptions about the Vyvanse coupon form can lead to confusion and misinterpretation. Here are some common misconceptions clarified:

The Vyvanse coupon form is only for those with insurance. This is incorrect. The coupon can also benefit individuals without insurance by providing discounts on their prescriptions.
Coupons provide unlimited use. This is a misconception. Coupons typically have limits on usage, often specified on the form itself.
You can use the coupon for any prescription medication. This is false. The coupon specifically applies to Vyvanse and is not valid for other medications.
All pharmacies accept the Vyvanse coupon. Not every pharmacy will accept the coupon. It is essential to verify with the pharmacy first.
Using a coupon means you have to forgo insurance benefits. This is misleading. In some cases, the coupon can be used alongside insurance to reduce out-of-pocket costs, but this varies by plan.
The coupon will always result in the lowest price. This is not necessarily true. Sometimes, insurance co-pays can be lower than the coupon price, so it’s wise to compare.
Applying for the coupon is too complicated. Some believe this, but in reality, the application process is often straightforward and user-friendly.
The coupon is only valid for a limited time after issuance. While coupons have expiration dates, many are renewed periodically, so it’s worth checking if a new one is available.

Key takeaways

When utilizing the Vyvanse Coupon form, it is essential to keep certain points in mind to ensure successful processing. Below are key takeaways to consider:

Payer Information: Familiarize yourself with the payer details listed on the coupon, including the payer name and Group Name.
Bin and PCN Numbers: Provide the appropriate BIN (004682) and PCN (CN) as required for verification.
Transaction Codes: Understand that the coupon supports multiple transaction codes, specifically B1 (Billing) and B3 (Re-bill).
Mandatory Fields: Ensure all mandatory fields indicated by "M" are filled out accurately. This includes the BIN number, version/release number, transaction code, and processor control number.
Service Provider Information: Enter the NPI (National Provider Identifier) of the service provider to facilitate the claim submission.
Patient Details: Include the patient's first name, last name, date of birth, and contact information, as these are necessary for processing.
Date of Service: Provide the date when the services were rendered. This is a mandatory requirement.
Quantity Dispensed: Accurately report the quantity dispensed in the appropriate field, as this can affect the claim's outcome.
Prior Authorization: If applicable, include a prior authorization number; this can determine how the claim is handled.
Other Coverage Information: Disclose any other insurance coverage that might apply, as this could influence how the claim is processed.

Reviewing these takeaways can aid in the proper completion and use of the Vyvanse Coupon form, ensuring that all necessary information is provided for claim processing.

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