1.

SEROQUEL

(quetiapine) 2.

SEROQUEL XR

(quetiapine)

1.

Concerta

(methylphenidate

hydrochloride extended-release)

1.

Eexor® XR

(venlafaxine HCL)

How this card works:

1. Present a valid new or rell prescription for a participating brand to your retail pharmacy.

2. Ask for the brand names below and provide the pharmacist with the RxHelp ONE™ card.

3. The RxHelp ONE™ program will (depending on the brand) pay up to the dierence between the brand medication and

the generic alternative.

I would like the following medications lled with brand name

product:

See RxHelpOne.com for a list of all medications covered on the

RxHelp ONE Program

Payment should be processed through ClaimSecure in the

following manner:

1. Select CLAIMSECURE as the drug plan, then enter the Cert, Group number (above), and select ‘CARDHOLDER’ as the

Relationship Code.

2. For electronic drug plans (public or private), enter the RxHelp ONE™ Program as the SECONDARY plan. If your patient

does not have a pay-direct plan, enter ClaimSecure as the primary plan.

ClaimSecure Pharmacy Help Desk: 1-800-461-6579

Your card number is:

00008001RX 37065