Nicotrol Patient Brochure - PfizerPro

”.fa.itSave on your next Nicotrol Inhaler prescriptionHow to use this coupon:SAVE2. Save up to $35 on your NICOTROLprescription instantly.1. Hand the Pharmacist your prescriptionwith this coupon.3. Also available on refills.These savings are good when presented witha valid, signed prescription for NICOTROL.No substitutions permitted.up to$35instantly*This coupon is not health insurance.*See Terms and Conditions on back.B:9.5”T:9”By using this coupon, you acknowledge that you currently meet the eligibility criteria and will comply with the terms and conditions described below:Eligibility Criteria: 1. This coupon is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, or other federal or state healthcare programs (including any state prescription drug assistanceprogram and the Government Health Insurance Plan available in Puerto Rico [formerly known as “La Reforma de Salud”]). This coupon is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other healthor pharmacy benefi t programs that reimburse you for the entire cost of your prescription drugs. This coupon is not health insurance. 2. Coupon is limited to $35 or the amount of your co-pay, whichever is less. Offer limited to $420per patient per year. 3. You must deduct the value of this coupon from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf. 4. This coupon is not valid for residents of Massachusetts whoseprescriptions are covered in whole or in part by third-party insurance, or where otherwise prohibited by law. Coupon cannot be combined with any other rebate/coupon, free trial, or similar offer for the specifi ed prescription. 5. Offer good only in theU.S. and Puerto Rico. Coupon is limited to 1 per prescription during this offering period and is not transferable. 6. Pfi zer reserves the right to rescind, revoke, or amend this offering without notice. Not available through mail order.This coupon will be accepted only at participating pharmacies.To the Pharmacist for a patient paying cash: Submit claim to Therapy First. A valid Other Coverage Code is required. Patient payment will be reduced by $35.00. You’ll receive this in your reimbursement from Therapy First plus a handling fee.To the Pharmacist for a patient with an Authorized Third Party: Submit claim to Primary Third Party Payer fi rst, then submit the balance due to Therapy First as a Secondary Payer as a co-pay only billing, using other Coverage Code Indication. Paymentwill be reduced by $35.00. You’ll receive this in your next reimbursement from Therapy First plus a handling fee.Submit this claim/information to Therapy First:Bin Number: 004682 RxPCN: CN Group ID: XXXXXXXX Cardholder ID: XXXXXXXFor any questions regarding Therapy First online processing, please call the Help Desk at 1-800-422-5604.I agree to the terms and conditions received with this coupon. No membership fees.For any questions, please call Customer Service at 1-877-465-6437. Pfizer Inc, 235 East 42nd Street, New York, NY 10017www.pfizer.comThis offer expires 03/31/12.NCU00092A ©2011 Pfi zer Inc. All rights reserved. Printed in USA/March 2011