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Microsoft word - terms and conditions.doc

PROPECIA—Persistence Program
Terms and Conditions
• Coupon is valid for new patients only. • Patients who have been taking PROPECIA for more than 90 days at the time of program enrollment are not eligible to use the coupon. Patients who have previously participated in the rebate offer for PROPECIA are not eligible to use the coupon. • Savings are limited to the amount of out-of-pocket cost for purchase. This program provides a maximum discount of up to $260 off the out-of-pocket
cost for a 1-year prescription of PROPECIA. The 1-year prescription may
be purchased in full during a single transaction (360 tablets), upon which
up to the full $260 discount will be applied, OR it may be purchased in four
90-day increments (90 tablets per transaction) over the course of 1 year,
upon which up to $60 will be received on the first fill and up to $200 will be
received on the fourth fill. Subsequent purchases need not be from the
same provider.
• Prescriptions for less than 90 days are not eligible for savings.
The coupon is valid for cash-paying patients only. Patient must make
full cash or cash equivalent payment for the prescription. The
coupon is not valid for prescriptions of PROPECIA for which you or
your pharmacy or dispensing physician receive (or are eligible to
receive) any reimbursement or price reduction through Medicaid,
Medigap, Medicare Part D or Medicare Advantage Plan, TRICARE,
CHAMPUS, VA, DOD, or similar federal or state programs, private
insurance, employer sponsored insurance, health maintenance
organization (HMO), preferred provider organization (PPO),
pharmacy benefits manager (PBM), or other health care programs.

• The coupon can be used only by residents of the United States. Coupon is not valid for residents of Maine or Massachusetts.
• The coupon is valid for MEN ONLY. Not valid for anyone younger than
• The coupon is valid at participating, eligible retail pharmacies in the United States. Mail-order pharmacies are not eligible. Eligible online pharmacies must be VIPPS®-accredited. The list of VIPPS®-accredited pharmacies may be found at www.nabp.net/index.html?target=/vipps/consumer/listall.asp. Product must originate and be dispensed in the United States. • Patient agrees not to seek reimbursement for all or any part of the benefit(s) received through this offer. No insurer or third party may pay for or reimburse any part of the prescription(s) filled with the coupon. • No other purchase is required. Limit 1 coupon per patient for the duration of the program. The coupon is nontransferable. No substitutions are permitted. May not be combined with any other free trial, coupon, discount, prescription savings card, or other offer. Void if reproduced. Void where prohibited by law, taxed, or restricted. • It is illegal for any person to sell, purchase, trade, or counterfeit the
• Merck & Co., Inc., reserves the right to rescind, cancel, or amend this offer at any time without notice. The coupon is the property of Merck & Co., Inc., and must be turned in on request. Visit propecia.com to view patient Product Information and physician Prescribing Information. • Program enrollment deadline: December 31, 2009. Program and
coupon expiration date: July 1, 2011.
• If you have any questions or wish to discontinue participating in the program, call 800-544-6542 (8 AM to 8 PM ET, Monday-Friday). • Direct Member Reimbursement (DMR)
For purchases of PROPECIA directly from a dispensing physician or a
VIPPS®-accredited online pharmacy or if the eligible retail pharmacy
chooses not to accept the coupon for PROPECIA—Persistence Program,
a Direct Member Reimbursement (DMR) form must be completed. Only
an original pharmacy receipt or a receipt from a dispensing physician or a
VIPPS®-accredited online pharmacy for PROPECIA will be accepted
(receipts will not be returned). Original receipts must be included with
the DMR form as outlined below in order to be eligible for the coupon
savings. Requests for Direct Member Reimbursement (DMR) forms
must be made within 30 days of purchase. DMR forms must be
returned to McKesson within 45 days of purchase.

Purchase of a 1-year supply
A request for a Direct Member Reimbursement (DMR) form for the
purchase of a 1-year supply (360 tablets) in a single transaction must be
made within 30 days of purchase. The original receipt must be included to
receive up to $260 off the purchase. The DMR form must be returned to
McKesson within 45 days of purchase.
Purchases of 90-day supplies
A request for a Direct Member Reimbursement (DMR) form must be made
within 30 days of purchase of the first fill of 90 tablets. The original receipt
must be included to receive up to $60 off the first fill of 90 tablets of
PROPECIA. The DMR form must be returned to McKesson within 45 days
of purchase.
DMR forms are not needed for the second and third fills of PROPECIA;
however, receipts for these purchases are required in order to be eligible for the final savings on the fourth fill. To be eligible for savings on the fourth fill of 90 tablets of PROPECIA, a request for a DMR form must be made within 30 days of purchase of the fourth fill. Original receipts must be included for the second, third and fourth fills to receive up to $200 off the fourth fill of 90 tablets. The DMR form must be returned to McKesson within 45 days of purchase. The DMR form must include the following information: • Patient name • Date of birth • Coupon ID number • Patient address • Patient phone number • Pharmacy or physician name • Pharmacy or physician address • Medication name • Prescription number • Quantity dispensed/days supply • Amount paid by patient • Date the prescription was filled (located on the receipt) For a copy of the DMR form, contact McKesson at 800-544-6542.

Source: http://www.daisdesigns39.com/PRC_CD_WebVersion/pdfs/terms_and_conditions.pdf

Dupage animal hospital

Dr. Gary Maves, Dr. Mary Felt, Dr. Angela Clark, Dr. Nicole DiGiacomo, Dr. Allison Roberts, Dr. Christopher Obradovich Owner’s Name : ___________________________ Pet’s Name: ____________________________ Date of Drop off : _____/______/________ Date of Pickup : _____/______/________ Feeding Directions: Brand of Food Vaccine Policy: To insure the protection of all pets

Modulo no 4

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