Welcome

This program is only available to residents of the United States and US territories (including the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands), except where prohibited. This program is valid for most eligible commercially insured and most eligible uninsured patients. Individuals who are enrolled in, or eligible for reimbursement under a government health care program, including Medicare, are not eligible to participate in this program. Terms, conditions and limitations apply. If your insurance changes, you may no longer be eligible to use this coupon.

To activate your coupon, please answer the following questions:

Do you have a coupon?

Yes

Please enter the 10-digit GRP# from the card you received*

Please enter a valid 10-digit GRP#.

Please enter the 11-digit ID# from the card you received*

Please enter a valid 11-digit ID#.

I certify that the patient, or caregiver activating on behalf of the patient, is 18 years or older and understand that any person 65 years of age or older without commercial insurance is not eligible to receive this offer.*

Yes

Please select Yes or No.

Is the patient who will be using this card eligible for reimbursement of prescriptions (in whole or in part) under any federal, state or other government programs including, but not limited to, Medicare (including Medicare Advantage and Part A, B and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare programs?*

Yes

Please select Yes or No.

Please confirm that, by clicking submit below to activate this coupon, you have read, understand and will comply with the terms and conditions of the program, that you currently meet all eligibility criteria and have read and agree with the Privacy Policy and Legal Notice.*

Yes

Please select Yes or No.

Please fill out the highlighted required fields above.

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