Free trial offer for BRAND
[Brand specific language describing free trial offer.]
Not all patients are eligible. Terms and Conditions apply.
If your doctor prescribed BRAND, and you are eligible, follow these steps to receive a free trial of BRAND:
Step 1: Terms and Conditions
Please review the Terms and Conditions
To continue, please scroll to read through all Terms and Conditions.
- Limit 1 voucher per patient per valid strength for the duration of the program. Patients who have previously redeemed a voucher for any strength are not eligible to redeem the voucher for that strength.
- Free trial offer is valid only for up to a 10-tablet trial supply. No purchase is necessary. Refills are not required.
- The voucher is not transferable. No substitutions are permitted. The offer cannot be combined with any other free trial, coupon, discount, prescription savings card, or other offer.
- The voucher is not insurance.
- Subject to changes in state law, this voucher may become invalid for residents of Massachusetts prior to its expiration date.
- You must be 18 years of age or older to redeem the voucher. Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the recipient through the offer. The free trial supply cannot be used toward any out-of-pocket costs under any plan (such as true out-of-pocket expense [TrOOP]).
- The voucher can be used only by eligible residents of the United States or the Commonwealth of Puerto Rico at participating eligible retail pharmacies in the United States or the Commonwealth of Puerto Rico. Product must originate in the United States or the Commonwealth of Puerto Rico.
Need help? Call 877-264-2454.
Free trial offer for BRAND
[Brand specific language describing free trial offer.]
Not all patients are eligible. Terms and Conditions apply.
If your doctor prescribed BRAND, and you are eligible, follow these steps to receive a free trial of BRAND:
Step 2: Patient Agreement
Accept the Patient Agreement
Need help? Call 877-264-2454.
Thank you!
Step 3: Print and/or download
Print the voucher
Print the voucher to bring to your pharmacist
Download the voucher
Download an image of the voucher to save on your device
To use this voucher, please show it, including the Pharmacist Instructions and Terms and Conditions, to the pharmacist with your valid prescription at pickup.
Need help? Call 877-264-2454.
HERE IS YOUR VOUCHER. PLEASE PRINT OR SAVE THE IMAGE.
Please read the accompanying Medication Guide for BRAND, including the information about [product specific information], and discuss it with your doctor. The physician Prescribing Information also is available.
BRAND is a prescription medication. Only your health care provider can decide whether BRAND is right for you.
How this voucher works
- This voucher is valid for 1 free 10‑tablet trial supply per valid strength of BRAND before the expiration date. Not valid for 5‑mg strength.
- To receive your free 10‑tablet trial supply of BRAND, take this voucher with your valid signed prescription to any participating eligible retail pharmacy (certain restrictions apply).
- There is no requirement to purchase any product or service to receive your free 10‑tablet trial supply of BRAND.
- Restrictions apply. Please see Terms and Conditions.
Please note: The same free trial offer may be available in different forms. For example, you may receive the voucher from your doctor, or you may print it yourself from the product Web site. Regardless of how many vouchers you receive or print, you may only use the voucher consistent with the Terms and Conditions.
Prescriber:
To initiate a free 10‑tablet trial supply for an appropriate patient, you should:
- Read the Prescribing Information before prescribing BRAND. For copies of the Prescribing Information, call 800‑672‑6372, visit belsomra.com, or contact your Merck representative.
- Write a prescription for up to a free 10‑tablet trial supply of BRAND. No substitutions are permitted. Not valid for 5‑mg strength.
- Refills are not required and there are no requirements to purchase any product or service to use this voucher. If you want your patient to continue taking BRAND beyond the free trial period, please write a separate prescription based on your recommended therapy.
- Give the valid signed prescription and this voucher to the patient along with the Medication Guide for BRAND.
- Eligible patients can take this voucher and the signed prescription to any participating eligible retail pharmacy to receive their free 10‑tablet trial supply.
- Restrictions apply. Please see Terms and Conditions.
Pharmacist:
- Only 1 voucher may be used per patient. Voucher may not be transferred to another patient. Not valid for 5‑mg strength.
- There is no requirement for patient to purchase any product or service and refills are not required.
- Please ensure that the medication and dosage strength match the medication and dosage strength on the prescription.
- Submit claim to McKesson Corporation using BIN No. 610524. For pharmacy processing questions, please call the McKesson Help Desk at 877‑264‑2454 (8 AM-8 PM ET, Monday-Friday).
- For any other prescriptions, please use the patient’s primary method of payment and a new Rx number.
- By processing this voucher, you agree that no claim for payment or reimbursement may be submitted for the free trial supply to any patient or any third‑party payer, including federal or state health care programs (Medicaid, Medicare [including true out‑of‑pocket expense (TrOOP)], Puerto Rico Government Health Insurance Plan [“Healthcare Reform”] or any other state or federal medical or pharmaceutical benefit or pharmaceutical assistance program), private insurers, and health or pharmacy benefit plans.
- Subject to changes in state law, this voucher may become invalid for residents of Massachusetts prior to its expiration date.
- McKesson Corporation reserves the right to audit and review all records and documentation relating to the redemption of this voucher and the dispensing of product.
- By accepting this voucher, you agree to the terms hereof.
Terms and Conditions:
- This voucher is valid for 1 free 10‑tablet trial supply of BRAND per valid strength.
- This voucher is not valid for the 5‑mg strength of BRAND.
- Limit 1 voucher per patient per valid strength for the duration of the program. Patients who have previously redeemed a voucher for any strength of BRAND are not eligible to redeem this voucher for that strength.
- Free trial offer is valid only for up to a 10‑tablet trial supply per valid strength of BRAND. No purchase is necessary. Refills are not required.
- This voucher is not transferable. No substitutions are permitted. This offer cannot be combined with any other free trial, coupon, discount, prescription savings card, or other offer.
- This voucher is not insurance.
- Subject to changes in state law, this voucher may become invalid for residents of Massachusetts prior to its expiration date.
- You must be 18 years of age or older to redeem this voucher. Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the recipient through this offer. The free trial supply cannot be used toward any out‑of‑pocket costs under any plan (such as true out‑of‑pocket expense [TrOOP]).
- This voucher can be used only by eligible residents of the United States or the Commonwealth of Puerto Rico at participating eligible retail 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 voucher is the property of Merck and must be turned in on request.
- It is illegal to sell, purchase, trade, or counterfeit or offer to sell, purchase, trade, or counterfeit this voucher. 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.
- Data related to your redemption of this voucher may be collected, analyzed, and shared with Merck, for market research and other purposes related to assessing voucher programs. Data shared with Merck will be aggregated and de‑identified, meaning it will be combined with data related to other voucher redemptions and will not identify you.
- Expiration Date: 11/30/2021.