*Terms and Conditions:
A patient is eligible for this promotion if their commercial health plan co-pay for PATADAY® Solution is more than $25 or if they have no prescription drug insurance coverage. Eligible patients will receive instant savings of up to $110 on out-of-pocket costs over $25. Total annual benefit limited to $1650.
This offer is not valid for patients who are enrolled in to Medicare Part D, Medicaid, Medigap, VA, DOD, Tricare, or any other government run or government sponsored heathcare program with a pharmacy benefit.
This offer is valid only in the United States. This offer may not be combined with any other rebate, discount, free trial, or other similar offer for the same prescription. Each voucher may be used by a single patient, but may be used for multiple prescriptions. This voucher will be accepted only at participating pharmacies. This voucher may not be redeemed for cash. This voucher is not health insurance. Alcon reserves the right to rescind, revoke, or amend this offer without notice at any time. The use of this voucher is subject to applicable state and federal laws. Please see instructions on reverse.
To the Patient: You must present this voucher to your pharmacist along with a valid prescription for PATADAY® Solution. If you purchase PATADAY® Solution through mail order and they do not accept this voucher, call McKesson Corporation at 877-264-2440 and request a Direct Member Reimbursement (DMR) form. When you use this voucher, you are certifying that you understand the program rules, regulations, and terms and conditions. In addition, you agree that you will not submit a claim for reimbursement to Medicare Part D, Medicaid, Medigap, VA, DOD, Tricare, or any other government run or government sponsored heathcare program with a pharmacy benefit. In addition, you agree that you will disclose this offer to your private insurer if requested or required to do so and that you will use this voucher consistent with your health insurer's policies, including not seeking reimbursement from your insurer for any amount that Alcon provides toward the voucher. If you have any questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the PATADAY® Solution program at 877-264-2440 (8:00 AM-8:00 PM EST, Monday- Friday).
To the Pharmacist: By submitting a request for reimbursement under this voucher, You agree to the terms and conditions of the voucher. You may not advertise or otherwise use the voucher to promote the services of your pharmacy. You agree that you will comply with the policies of the patient's insurer and will not request payment from Alcon where the voucher is prohibited by the patient's insurer or applicable law. When you use this voucher, you are certifying that you have not submitted and will not submit a claim for reimbursement for this prescription to Medicare Part D, Medicaid, Medigap, VA, DOD, Tricare, or any other government run or government sponsored heathcare program with a pharmacy benefit.
- Submit transaction to McKesson Corporation using BIN #610524.
- If primary coverage exists, input voucher 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 voucher and your submission of claims for the PATADAY® Solution program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc.
- For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for PATADAY® Solution program at 877-264-2440 (8:00 AM- 8:00 PM EST, Monday-Friday).