Coverage
& Savings

Learn about formulary coverage
and patient savings

Coverage & Access

Patient Savings Card

Patient savings card

BIN#:600428

PCN#:06780000

GRP#:06780139

ID#: xxxxxxxxxxxx

With the Adhansia XR Savings Card, you may pay as little as $15 on each prescription. Maximum limits apply; patients’ out‑of‑pocket expenses may vary. The patient is responsible for the first $15 and any amount that exceeds the total Adhansia XR Patient Savings offer.

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Patient savings card

BIN#:600428

PCN#:06780000

GRP#:06780139

ID#: xxxxxxxxxxxx

TERMS & CONDITIONS

PATIENT INSTRUCTIONS: You must present this card to the pharmacist along with your prescription for Adhansia XR (methylphenidate HCl) extended-release capsules, CII to participate in this program. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the Adhansia XR Patient Savings Program at 1-866-420-77191-866-420-7719 (available 24 hours/day except major holidays). When you use this card, you are certifying that you understand the program rules, regulations, and terms and conditions.

TO THE PHARMACIST: Savings Card can only be used when accompanied by a valid prescription for Adhansia XR. For insured patients, process a Coordination of Benefits (COB) claim using the patient’s prescription insurance for the primary claim. Submit a secondary claim to DST (formerly Argus), using BIN: 600428/PCN: 06780000. Return card to patient and remind them to retain for future use. For questions regarding claim transmission, please call the TrialCard Help Desk at 1-866-420-77191-866-420-7719. By submitting this card for reimbursement you certify that:

  • You have dispensed the covered drug to an eligible patient in accordance with the terms of the card and accompanying prescription
  • Other than TrialCard, you have not submitted and will not submit a claim for reimbursement to any Third Party Payor that prohibits use of the card, including Medicare, Medicaid, any similar federal or state healthcare program, or any patient assistance programs; and
  • Your participation in this program is consistent with all applicable laws and with all of your contractual or other obligations

Eligibility Requirements
This card is valid only for patients with commercial (private or non-governmental) insurance. It is not valid for patients (i) who are government beneficiaries or whose prescription drugs are eligible to be reimbursed, in whole or in part, by any Federal Health Care Program, as that term is defined at 42 U.S.C. §1320a-7b(f), including Medicaid, Medicare, a Medicare Part D or Medicare Advantage plan, TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan, or any other state or federal health care program; (ii) who are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees; or (iii) who reside in a state where the card is prohibited.

Terms and Conditions
You must meet eligibility requirements. This card is only available with a valid prescription. The card is not valid for medications you received for free or that are eligible to be reimbursed by private insurance plans or any other healthcare pharmaceutical assistance programs that reimburse you for the entire cost of your medications. You agree not to seek reimbursement for all or any part of the benefit received through this offer. You agree to report your use of this card to any third party that reimburses you or pays for any part of the prescription price. You additionally agree that you will not submit any portion of the product dispensed pursuant to this card to a federal or state healthcare program for purposes of counting it toward your out‑of‑pocket expenses. This card has no cash value and is not valid with any other program, discount, or incentive involving the covered medication. Use of this card must be consistent with all relevant health insurance requirements and payer agreements. Participating patients, pharmacies, physician offices, and hospitals are obligated to inform third-party payers about the use of the card as provided for under the applicable insurance or as otherwise required by contract or law. This card may not be sold, purchased, traded, or offered for sale, purchase, or trade. This card is limited to one per person during the offering period and is not transferable. This offer is not contingent upon any past, present, or future purchases of the covered medication or any other product, and this offer may be rescinded, revoked, or amended without notice. No reproductions. This card is not health insurance or a benefit plan. This card is void where prohibited or where restricted beyond the terms herein. Maximum benefits apply. For questions about this card, call 1-866-420-77191-866-420-7719.

Adlon Therapeutics L.P. reserves the right to rescind, revoke, or amend this offer without notice at any time.

PREVIOUS PAGE Responsible
Stimulant Use

Important Safety Information

Contraindications

Adhansia XR is contraindicated in patients with a known hypersensitivity to methylphenidate or other components of Adhansia XR. Hypersensitivity reactions such as angioedema and anaphylactic reactions have been reported in patients treated with other methylphenidate products. Adhansia XR is also contraindicated in patients receiving concomitant treatment with monoamine oxidase inhibitors (MAOIs), and also within 14 days following discontinuation of treatment with a MAOI, because of the risk of hypertensive crisis.

Warnings and Precautions

Potential for Abuse and Dependence

CNS stimulants, including Adhansia XR, other methylphenidate-containing products, and amphetamines, have a high potential for abuse and dependence. Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy.

Serious Cardiovascular Events

Sudden death, stroke and myocardial infarction have occurred in adults treated with CNS stimulant treatment at recommended doses. Sudden death has occurred in pediatric patients with structural cardiac abnormalities and other serious cardiac problems taking CNS stimulants at recommended doses for ADHD. Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious heart arrhythmia, coronary artery disease, and other serious heart problems. Further evaluate patients who develop exertional chest pain, unexplained syncope, or arrhythmias during Adhansia XR treatment.

Blood Pressure and Heart Rate Increases

CNS stimulants cause an increase in blood pressure (mean increase approximately 2 to 4 mmHg) and heart rate (mean increase approximately 3 to 6 bpm). Individuals may have larger increases. Monitor all patients for hypertension and tachycardia.

Psychiatric Adverse Reactions

CNS stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a pre-existing psychotic disorder.

CNS stimulants may induce a manic or mixed episode in patients. Prior to initiating treatment, screen patients for risk factors for developing a manic episode (e.g., comorbid or history of depressive symptoms or a family history of suicide, bipolar disorder, or depression).

CNS stimulants, at recommended doses, may cause psychotic or manic symptoms (e.g., hallucinations, delusional thinking, or mania) in patients without a prior history of psychotic illness or mania. If such symptoms occur, consider discontinuing Adhansia XR. In a pooled analysis of multiple short-term, placebo-controlled studies of CNS stimulants, psychotic or manic symptoms occurred in approximately 0.1% of CNS stimulant-treated patients, compared to 0% in placebo-treated patients.

Priapism

Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products, in both pediatric and adult patients. Priapism was not reported with drug initiation but developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.

Peripheral Vasculopathy, including Raynaud's Phenomenon

CNS stimulants, including Adhansia XR, used to treat ADHD are associated with peripheral vasculopathy, including Raynaud's phenomenon. Signs and symptoms are usually intermittent and mild; however, very rare sequelae include digital ulceration and/or soft tissue breakdown. Effects of peripheral vasculopathy, including Raynaud's phenomenon, were observed in post-marketing reports at different times and at therapeutic doses in all age groups throughout the course of treatment. Signs and symptoms generally improve after reduction in dose or discontinuation of drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants. Further clinical evaluation (e.g., rheumatology referral) may be appropriate for certain patients.

Long-Term Suppression of Growth

CNS stimulants have been associated with weight loss and slowing of growth rate in pediatric patients.

Careful follow-up of weight and height in pediatric patients ages 7 to 10 years who were randomized to either methylphenidate or non-medication treatment groups over 14 months, as well as in naturalistic subgroups of newly methylphenidate-treated and non-medication treated pediatric patients over 36 months (to the ages of 10 to 13 years), suggests that consistently medicated pediatric patients (i.e., treatment for 7 days per week throughout the year) have a temporary slowing in growth rate (on average, a total of about 2 cm less growth in height and 2.7 kg less growth in weight over 3 years), without evidence of growth rebound during this period of development.

Closely monitor growth (weight and height) in pediatric patients treated with CNS stimulants, including Adhansia XR. Patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.

Allergic-Type Reactions FD&C Yellow No. 5

Adhansia XR 45 mg capsules contain FD&C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible persons. Although the overall incidence of FD&C Yellow No. 5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also have aspirin hypersensitivity.

Adverse Reactions

The most common (≥5% and twice the rate of placebo) adverse reactions occurring with Adhansia XR in adults are insomnia, dry mouth, and decreased appetite.

The most common (≥5% and twice the rate of placebo) adverse reactions occurring with Adhansia XR in pediatric patients are decreased appetite, insomnia, and weight decreased.

Pregnancy Exposure Registry

There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to Adhansia XR during pregnancy. Healthcare providers are encouraged to register patients by calling the National Pregnancy Registry for Psychostimulants at 1-866-961-23881-866-961-2388.

To report SUSPECTED ADVERSE REACTIONS, contact Purdue Pharma L.P. at 1-888-726-75351-888-726-7535 or FDA at 1-800-FDA-10881-800-FDA-1088 or www.fda.gov/medwatch.

Please read Full Prescribing Information, including Boxed Warning.

Reference: 1. Adhansia XR™ (methylphenidate HCl) prescribing information. Stamford, CT: Purdue Pharma L.P.

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