SAVE 50%

Transcription

SAVE 50%
SAVE 50% on 3 prescriptions
Print and take this page with your prescription to the pharmacy
to save on each of your 3 prescriptions.
SAVE 50%
on 3 prescriptions
This isis not
nothealth
healthinsurance.
insurance.
BIN: 600428 Group: 06780032 PCN: 06780000 ID: 44055747608
No membership fees.
To Patient: Redeem at retail pharmacy.
To Pharmacist:
• F or Privately Insured Patients: Process a coordination of benefits (COB/split bill) claim using patient’s prescription insurance for the PRIMARY claim. Submit SECONDARY claim
to ARGUS using BIN: 600428 and PCN: 06780000.
• F or Federal, State, or Other Government-Insured Patients: By processing this savings offer, you certify that no claim will be submitted for reimbursement under any
federal, state, or other governmental programs for this prescription. Medicare Part D patients may use the offer ONLY if paying the full cash price and no claim is submitted to
Medicare. Patients enrolled in Medicare Part D plans that cover the prescription as a supplemental benefit are ineligible for the offer even if paying cash.
• F or Uninsured or Cash Patients: Submit claim to ARGUS using BIN: 600428 and PCN: 06780000.
For help processing this card, call 1-877-822-7971.
By using this offer (the “Card”), you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:
• The Card is not valid for prescriptions that are eligible to be reimbursed, in whole or in
part, by Medicaid, Medicare, Medicare Part D plans as a supplemental benefit under
enhanced alternative coverage, or other federal or state healthcare programs, including
any state prescription drug assistance programs and the Government Health Insurance
Plan available in Puerto Rico (formerly known as “La Reforma de Salud”).
• Medicare Part D patients may use the Card if paying the full cash price for a prescription
covered by the Card and no claim is submitted to Medicare or any other federal, state,
or other governmental program. Out-of-pocket expenses incurred using the Card
cannot be applied towards Medicare Part D true out-of-pocket (TrOOP) expenses.
Patients enrolled in Medicare Part D plans that cover the prescription as a
supplemental benefit are not eligible to use the Card even when paying cash.
• The Card is not valid for prescriptions that are eligible to be reimbursed by private
insurance plans or other health or pharmacy benefit programs which reimburse you
for the entire cost of your prescription drugs.
• The Card is limited to 50% savings off the amount of your co-pay or your out-of-pocket
cost, with a maximum savings of $150 off each prescription for up to three uses.
A minimum of 6 pills per prescription is required. Total maximum savings for this
offer are $450.
The blue diamond tablet shape is a registered trademark of Pfizer Inc.
© 2015 Pfizer Inc. All rights reserved. October 2015
Pfizer, PO Box 29387, Mission, KS 66201-9618 1-888-4-VIAGRA
www.VIAGRA.com
VGU766717-01
• You must deduct the value received under this program from any reimbursement
request submitted to your insurance plan, either directly by you or on your behalf.
• The Card cannot be combined with any other rebate/coupon, free trial, or similar offer
for the specified prescription.
• The Card will be accepted only at participating pharmacies.
• This Card is not health insurance.
• No membership fees are associated with this offer.
• Offer good only in the U.S. and Puerto Rico.
• The Card is limited to 1 per person per year and is not transferable.
• Pfizer reserves the right to rescind, revoke, or amend the offer without notice.
• Offer expires 12/31/2016.

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