DEXILANT (dexlansoprazole) INSTANT SAVINGS CARD ELIGIBILITY RULES
Eligibility Requirements: This offer cannot be used if you are a beneficiary of, or any part of your prescription is covered by: (1) any federal, state, or government-funded healthcare program (for example, Medicare, Medicaid, TRICARE), including a state pharmaceutical assistance program (the Federal Employees Health Benefits (FEHB) Program is not a government-funded healthcare program for purposes of this offer), (2) the Medicare Prescription Drug Program (Part D), or if you are currently in the coverage gap, or (3) insurance that is paying the entire cost of the prescription.
Terms & Conditions: You must meet Eligibility Requirements. You agree to report your use of this offer to any Third Party that reimburses you or pays for any part of the prescription price. Use of this offer is confirmation that you are permitted, under the terms and conditions of the health benefit plan(s) covering your prescriptions, to take advantage of co-pay coverage programs. You additionally agree that you will not submit the cost of any portion of the product dispensed pursuant to this offer to a federal or state healthcare program for purposes of counting it toward your out-of-pocket expenses. For commercially insured patients, this savings card covers out-of-pocket expenses greater than $20, up to a maximum benefit of $55 for a 30-day prescription or $165 for a 90-day prescription. For uninsured patients, the amount of this offer is not to exceed $55 for a 30-day prescription or $165 for a 90-day prescription. This coupon is not valid with any other program, discount, or incentive involving DEXILANT (dexlansoprazole). This offer may be rescinded, revoked, or amended without notice. No reproductions. This offer is void where prohibited by law, taxed, or restricted. Limit one offer per purchase. Cash value of [1/100 of 1¢.] For questions about this offer, call the Customer Service Center at 1-866-279-5598.
Pharmacy Instructions: By submitting this offer for reimbursement to McKesson, you certify that: (1) you have dispensed DEXILANT to an eligible patient in accordance with the Eligibility Requirements of this offer and the accompanying prescription; (2) you have not submitted and will not submit a claim for reimbursement for the portion of the drug covered by this coupon to any payor; (3) your participation in this program is consistent with all applicable laws and any obligations, contractual or otherwise, that you may have as a pharmacy provider; and (4) submission of claims are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc. For questions about processing, please call 1-866-279-5598.