Eligible patients may save up to $15
off on each of up to 6 qualifying prescriptions for PROVENTIL HFA.
PROVENTIL HFA is a prescription
medication. Only your health care provider can decide if PROVENTIL
HFA is right for you.
How this coupon works:
- This coupon can be used up to 6 times before the expiration
date and provides a maximum benefit of up to $15 or the amount of
your out-of-pocket cost, whichever is less, off on each of up to 6
- To receive up to $15 in savings on your out-of-pocket cost
for PROVENTIL HFA, present this coupon and your insurance card (if
any) with a valid signed prescription at any participating eligible
retail or mail-order pharmacy (certain restrictions apply).
- If you are unable to redeem this coupon at your eligible
retail or mail-order pharmacy, please keep your receipt and call
McKesson Corporation at 877-264-2440 within 30 days of purchase to
request a Direct Member Reimbursement (DMR) form.
- No other purchase is necessary. Restrictions apply. Please see Terms and Conditions.
To initiate a coupon for an appropriate patient to use up
to 6 times, you should:
- Read the Prescribing Information before
prescribing PROVENTIL HFA.
- Write a prescription for PROVENTIL HFA. No substitutions
- Give the signed prescription and this coupon to the
- Eligible patients can take or send this coupon and the
signed prescription to any participating eligible retail or
mail-order pharmacy to receive savings on their out-of-pocket cost
(savings will vary depending on their out-of-pocket cost).
- For copies of the Prescribing Information, call
800-672-6372, visit proventilhfa.com, or contact your Merck
- Not all patients are eligible to use this coupon. Please see Terms and Conditions.
- Coupon is valid only when accompanied by a prescription
for PROVENTIL HFA. Coupon value may not exceed actual
out-of-pocket cost or $15, whichever is less. Please
review Terms and Conditions on coupon for important eligibility
- Submit transaction to McKesson Corporation
using BIN No. 610524.
- If primary coverage exists, input coupon information as
secondary coverage and transmit using the COB segment of the NCPDP
transaction. Applicable discounts will be displayed in the
transaction response. For cash-paying patients, Pharmacist agrees
to charge no more than the usual and customary retail price.
- For all other prescriptions, please use the patient's
primary method of payment and a new RX number. Please clear COB
secondary screen after processing transaction.
- Acceptance of this coupon and your submission of claims
are subject to the Terms and Conditions, posted at
www.mckesson.com/mprstnc, and the Terms and Conditions of this
- By processing this coupon, you agree that PROVENTIL HFA
was dispensed pursuant to this coupon and that you will not submit
a claim for reimbursement to Medicaid, Medicare, or any other
state, federal, or other government program. You also agree not to
submit any claim for reimbursement to any third-party payer who
reimburses or pays any part of the prescription price or otherwise
provides coverage for PROVENTIL HFA for Massachusetts residents.
- You agree to notify the patient's insurance carrier of
this coupon redemption, as may be required by the Terms and
Conditions of your relationship with the insurance carrier.
- This coupon may not be applied toward any other pharmacy
- For pharmacy processing questions, please
call the Help Desk at 877-264-2440 (8 AM-8 PM ET, Monday-Friday).
Terms and Conditions
- This coupon is valid for up to $15 off on each of up to 6
qualifying prescriptions for PROVENTIL HFA.
- Limit 1 coupon per patient for the duration of the
- Coupon is valid for use 6 times only. Patient must have a
copayment or make full cash payment for the prescription. Savings
are limited to amount of your out-of-pocket cost, up to a maximum
of $15 per prescription for up to 6 qualifying prescriptions.
- No other purchase is necessary.
- This coupon is not transferable. No substitutions are
permitted. Cannot be combined with any other coupon, free trial,
discount, prescription savings card, or other offer.
- This coupon is not insurance.
- This coupon is valid for patients with private insurance
or cash-paying patients. Not valid for
patients covered under Medicaid, Medicare, a Medicare Part D or
Medicare Advantage plan (regardless of whether a specific
prescription is covered), TRICARE, CHAMPUS, Puerto Rico
Government Health Insurance Plan ("Healthcare Reform"), or any
other state or federal medical or pharmaceutical benefit program
or pharmaceutical assistance program.
- This coupon is void for Massachusetts
residents if a third-party payer reimburses or pays any amount of
the prescription price or otherwise provides coverage for
- You must be 18 years of age or older to redeem this coupon
for yourself or minor. Patient, guardian, pharmacist, and
prescriber agree not to seek reimbursement for all or any part of
the benefit received by the recipient through this offer. Patient
or guardian is responsible for reporting receipt of coupon benefit
to any insurer, health plan, or other third party who pays for or
reimburses any part of the prescription filled using this coupon,
as may be required.
- This coupon can be used only by eligible United States or
Commonwealth of Puerto Rico residents at participating eligible
retail or mail-order pharmacies in the United States or the
Commonwealth of Puerto Rico. Product must originate in the United
States or the Commonwealth of Puerto Rico.
- This coupon is the property of Merck and must be turned in
- It is illegal to sell, purchase, trade, or
counterfeit, or offer to sell, purchase, trade, or counterfeit
this coupon. Void if reproduced. Void where prohibited by law,
taxed, or restricted.
- Merck reserves the right to rescind, revoke, or amend this
offer at any time without notice.
- Please read the Patient Information and
discuss it with your doctor.
- Expiration Date: 06/30/2013.
Copyright © 2012 Merck Sharp & Dohme Corp., a subsidiary of Merck
& Co., Inc. All rights reserved