|
A2342
How to get your rebate:
- Print the rebate request form by clicking “Print this page” icon on this page.
- Fill in the required information.
- Sign the request form and send it with your original pharmacy receipt or your receipt from a dispensing physician or VIPPS®-accredited online pharmacy that indicates your purchase of PROPECIA® (finasteride) to the following address:
Rebate Program for PROPECIA
PO Box 748
Horsham, PA 19044-9462
If you satisfy all terms and conditions outlined below, you will be reimbursed $25 of your product cost. Please allow 6 to 8 weeks for your check to arrive. Click here to learn about VIPPS® and to view a list of VIPPS®-accredited online pharmacies.
Terms and Conditions:
Rebates are not valid for prescriptions for which you or your pharmacy received (or are eligible to receive) any reimbursement or price reduction under Medicaid, Medicare, or similar federal or state programs; private insurance; a health maintenance organization; a pharmacy benefits manager (PBM); or other healthcare programs. Offer void where prohibited by law.
This offer is good for MEN ONLY.
Rebates are valid only for prescriptions of PROPECIA paid in full by you. Your payments may be paid in cash, billed to a debit card, or charged to a credit card. Neither you nor your pharmacy nor your dispensing physician can have received or be eligible to receive any reimbursement for some or all of your prescription cost.
To be eligible for reimbursement under this offer, this coupon must be accompanied by an original pharmacy receipt or a receipt from a dispensing physician or a VIPPS®-accredited online pharmacy for PROPECIA that states the following (receipt will not be returned):
- Date the prescription was filled
- Name of prescribed product
- Quantity of prescription
- Store, physician, or online pharmacy identification
- Cost of the product
- Patient’s name
Offer good only in the United States for PROPECIA dispensed from a pharmacy or physician in the United States and cannot be combined with other offers or discounts.
Patients who have previously sought reimbursement under the 12-month Promise of PROPECIA program are not eligible to receive rebates on their purchases of PROPECIA.
Prescription quantities for less than 90 days are not reimbursable under this offer.
Not valid for anyone younger than age 18. Offer expires on June 30, 2008.
By submitting this rebate request, you certify that you paid for your prescription in full and satisfy all terms and conditions of the rebate offer.
A2342
Items marked with an * are required.
Please understand that your name and medical information will be held in strict confidence by the administrators of this program working on behalf of Merck & Co., Inc. (Merck), maker of PROPECIA® (finasteride). The information you provide is necessary for these administrators to conduct data processing, mailings, and follow-up related to the program. As necessary, these administrators may contact you, your doctor, and your insurance or prescription provider to verify your eligibility for this program.
By signing below, you agree to the terms and conditions above and to the use of information about you for the purposes described above. You also agree that you will not seek reimbursement from any other party for the amount you paid as shown on the enclosed receipt for this prescription. At any time, you can request a copy of this form and that personal and medical information about you be removed from the contact list for this program by contacting 1-888-776-8364. I understand that unless I change my instructions sooner, my permission will expire 180 days from the date of signing this authorization.
|
Privacy Policy
