Use this coupon to save up to $20 off your next prescription of VERAMYST® (fluticasone furoate) Nasal Spray.
TO THE PATIENT:
- Present this COUPON, and if applicable, your insurance card, with your prescription for the GlaxoSmithKline product at any participating pharmacy.
- You will receive up to $20 off your out-of-pocket cost (the amount you pay after the insurance deductions).
- This coupon is nontransferable. Duplicates of this uniquely coded coupon are invalid and not redeemable at the pharmacy.
- To aid in processing, please present this coupon when you DROP OFF your prescription.
- If you use a mail-order pharmacy, please contact your pharmacy provider to ensure that this offer will be accepted.
- Offer limited to 1 coupon per purchase.
ELIGIBILITY REQUIREMENTS
By redeeming this coupon, I, the Patient, certify that: (i) I have read the enclosed program rules and regulations, terms and conditions, (ii) I
have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription,
(iii) if I am Medicare eligible, I am not enrolled in an employer-sponsored health plan for retirees or a Medicare Part D Plan, and (iv) I will
otherwise comply with the terms above.
This coupon is the property of GlaxoSmithKline (GSK) and must be returned upon request. GSK retains the right to rescind, revoke or amend this offer without notice. Not valid for patients under Medicaid, Medicare, or similar state or federal programs. Not valid for residents of Massachusetts unless paying the full cost of the prescription. This offer may not be combined with any other free product trial, discount check, discount or prescription savings card. Offer good only in USA.
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.
PROCESSOR: McKesson Corporation
Expiration date:
Sun Jul 1, 2012
RxBIN# 610524 RxGROUP# 50776237 ID# 828584135 RxPCN: Loyalty ISSUER# (80840)
For pharmacy processing questions, please call the Help Desk at 1-866-747-1170.
Hours of operation: Monday–Friday 8AM–9PM ET and Saturday 9:30AM–6PM ET, excluding holidays.
©2012 The GlaxoSmithKline Group of Companies All rights reserved. VRM346R0 January 2012