TO THE PHARMACIST: Please submit the amount of co-pay authorized by the patient’s primary insurance as a secondary transaction to McKesson Corporation.
By redeeming this coupon, I certify that: (i) I have received this coupon from an eligible patient, (ii) I have dispensed the product as indicated, (iii) I have not submitted, and will not submit, a claim for reimbursement to the patient or any federal, state, or other governmental payer or to any Medicare Part D Plan, (iv) I have not retained or provided to any person or entity any portion of the amount being made available to the patient, and (v) I will otherwise comply with the terms hereof. I further certify that my participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that I have as a pharmacy provider.
It is a violation of federal law to buy, sell, or counterfeit this coupon.
For pharmacy processing assistance or questions, please call the Help Desk at 1-866-747-1170 (Monday - Friday 8:00 AM - 9:00 PM ET, Saturday 9:30 AM - 6 PM ET, excluding holidays).
TO THE PATIENT: This coupon can be used whether or not you have insurance for the amount of your out-of-pocket expense for this prescription, up to a maximum of $50 per use. This coupon must be accompanied by a valid, signed prescription. You are NOT eligible to use this coupon if you are a government beneficiary. You are a government beneficiary if this prescription is covered by or will be submitted for reimbursement under any federal healthcare program, including Medicaid, Medicare (Part D or otherwise), or any similar federal or state programs, including any state pharmaceutical assistance program. Further, you MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan or employer-sponsored prescription drug benefit plan for retirees (ie, you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer).
Not valid in Massachusetts if AB-rated generic drug is available for the product. Your acceptance of this offer must be consistent with terms of any drug benefit plan provided to you by your health insurer. You agree to report your use of this coupon to your health insurer if required. Only original accepted—not valid if reproduced. One per purchase. May not be used with any other discount or offer. Offer good only in USA. Void where prohibited by law, taxed, or restricted.
Stiefel and McKesson (on Stiefel’s behalf) reserve the right to rescind, revoke, or amend this coupon without notice.
By redeeming this coupon, I, the Patient, certify that: (i) I have read and will comply with program rules and requirements, (ii) I have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription, and (iii) if I am Medicare eligible, I am not enrolled in an employer-sponsored health plan for retirees or a Medicare Part D Plan.
This coupon is the property of Stiefel and must be returned upon request.