$17

CO-PAY*

Good for up to 12 benefits per calendar year

RxBIN:
610524
RxPCN:
Loyalty
RxGRP:
50777518
ISSUER:
(80840)
ID#:
1263398824

TO THE PATIENT

You must present this card to the pharmacist along with your prescription to participate in this program.

If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the Alvesco Savings program at 1-877-264-2440 (8:00 AM-8:00 PM EST, Monday-Friday).

When you use this card, you are certifying that you understand the program rules, regulations, and terms and conditions. This coupon is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare (including Medicare Part D and Medicare Advantage), TriCare, CHAMPUS, or any other local, state or federal healthcare programs, including state prescription drug assistance programs and the La Reforma de Salud program in Puerto Rico; and you will otherwise comply with the terms above.

* Most insured patients will pay no more than $17 monthly with a maximum benefit of $75 per fill. Restrictions apply and co-pay amounts may vary.

TO THE PHARMACIST

When you use this card, you are certifying that you have not submitted and will not submit a claim for reimbursement under any state or federal government programs for this prescription.

  • Submit transaction to McKesson Corporation using BIN #610524
  • If primary commercial prescription insurance exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
  • Acceptance of this card and your submission of claims for the Alvesco Savings program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc
  • This coupon is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare (including Medicare Part D and Medicare Advantage), TriCare, CHAMPUS, or any other local, state or federal healthcare programs, including state prescription drug assistance programs and the La Reforma de Salud program in Puerto Rico.
  • For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript for the Alvesco Savings program at 1-877-264-2440 (8:00 AM-8:00 PM EST, Monday-Friday).
  • Covis Pharma reserves the right to rescind, revoke or amend this offer at any time.
Alvesco is a registered trademark of Astra Zeneca AB, used under license.
© Copyright 2017 Astra Zeneca & Covis Pharma. All rights reserved. ALV001-17 08/17