Use this coupon to get your first full prescription of VERAMYST - FREE

PATIENTS:

Present your prescription, along with this coupon, to your pharmacist to receive your first full prescription of VERAMYST -- FREE
If you prefer not to be contacted or to receive future communications, please visit www.imgw.com/forms/gwirrf.html or call 1-888-825-5249.
Offer limited to patients receiving their first full prescription for VERAMYST.
Limit one free trial per person. Offer not transferable.

To aid in processing, please present this coupon when you DROP OFF your prescription, NOT when you pick up.

TO THE PATIENT

You may use this coupon only for free product. That is, in order to be eligible for this offer, this coupon must be accompanied by a valid, signed prescription for 120 metered sprays of VERAMYST^® (fluticasone furoate) Nasal Spray. Further, you are NOT eligible for this offer if either: (a) this prescription 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, or under any private insurance, HMO, or other third-party payment arrangement, or (b) any part of this prescription will be submitted to count toward your out-of-pocket cost under your prescription drug plan, such as the “True Out-Of-Pocket (TrOOP)” expenses under Medicare Part D. Only an original coupon will be accepted and must be presented to your pharmacist at the time you have your prescription filled — not valid if reproduced. Offer good only in USA. Void where prohibited by law, taxed or restricted. No purchase required. May not be used with any other discount, coupon or other offer. GlaxoSmithKline reserves the right to rescind, revoke, or amend this coupon without notice.

By tendering this coupon, I, the Patient, certify that (i) I have read the above terms, (ii) I am not being reimbursed by, nor will I submit a claim for reimbursement, nor will I seek to have any portion of this prescription counted toward my out-of-pocket costs (eg, TrOOP), under any federal, state, or private programs for this prescription, and (iii) I will otherwise comply with the terms above. Offer limited to patients receiving their first full prescription for VERAMYST.

TO THE PHARMACIST

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) a claim for reimbursement to the patient or to any third-party payor, governmental or otherwise, or (b) any portion of this prescription to a third-party payor for purposes of counting it toward the patient’s out-of-pocket expenses (such as TrOOP under Medicare Part D), and (iv) 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.

Expiration Date: Tue Nov 04, 2008 Group: H2000200 Member: U55269531

Pharmacist: Submit claim to McKesson using BIN #610500. For pharmacy processing questions, please call the Help Desk at 1-800-750-9835.