TO THE PHARMACIST: By redeeming each savings represented by this savings card, I certify that (i) I have received this savings card 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.
TO THE PATIENT: By redeeming this savings card, 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 or prescription drug plan for retirees, or a Medicare Part D Plan, and (iv) I will otherwise comply with the terms above.
Not valid for patients under Medicaid, Medicare (including Medicare Part D), or similar state or federal programs, or for residents of Puerto Rico. Not valid for residents of Massachusetts unless you are paying the full cost of the prescription.
This offer may not be combined with any other free product trial, coupon, or discount check, or with any discount or prescription savings card.
Patient Instructions: Present this savings card, your pharmacy benefits insurance card, and your prescription for OLUX-E® (clobetasol propionate) Foam, 0.05% at any participating pharmacy. You will receive a savings of up to $50 off your out-of-pocket cost (the amount you pay after the insurance deductions) for such prescription. If you have any questions regarding your eligibility or benefits or if you wish to discontinue your participation, call 1-866-829-1452 (8:00 AM-8:00 PM EST, Monday-Friday, and 9:30 AM-6:00 PM EST, Saturday).
Pharmacist Instructions: Please submit the amount of co-pay authorized by the patient's primary insurance as a secondary transaction to McKesson Corporation using BIN #610524. Transmit using the COB segment of the NCPDP transaction. This savings card is the property of Stiefel and McKesson Corporation and must be returned upon request. Both parties retain the right to rescind, revoke, or amend this program without notice. For questions regarding setup, claim transmission, patient eligibility, or other issues, call 1-866-829-1452 (8:00 AM-8:00 PM EST, Monday-Friday, and 9:30 AM-6:00 PM EST, Saturday).