To the Patient:
This card can be used whether or not you have insurance for the amount of your out-of-pocket expense for this prescription, up to a maximum of $200 per monthly supply. This card must be accompanied by a valid, signed prescription. You are NOT eligible to use this card if you are a government beneficiary. You are a government beneficiary if this prescription is covered by, or a claim relating to this prescription will be submitted for reimbursement under, any federal healthcare program, including Medicaid, Medicare (Part D or otherwise), or any similar federal or state programs, including any state pharmaceutical assistance program. Further, you MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan or employer-sponsored prescription drug benefit plan for retirees (ie, you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). You agree to promptly notify ViiV Healthcare if you become a government beneficiary after activation of this card.
Not valid in Massachusetts if AB-rated generic drug is available for the product. Your acceptance of this offer must be consistent with terms of any drug benefit plan provided to you by your health insurer. You agree to report your use of this card to your health insurer if required. Only original accepted—not valid if reproduced. One per purchase of a ViiV Healthcare medicine. May not be used with any other discount or offer. Offer good only in US, including Puerto Rico. Void where prohibited by law, taxed, or restricted.
ViiV Healthcare and McKesson (on the behalf of ViiV) reserve the right to rescind, revoke, or amend this card without notice.
By redeeming this card, I, the Patient, certify that: (i) I have read and will comply with program rules and requirements, (ii) I have not submitted and will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription, and (iii) if I am Medicare eligible, I am not enrolled in an employer-sponsored health plan for retirees or a Medicare Part D Plan.
Mail-order: If you use a mail-order pharmacy, please contact your pharmacy provider to ensure that this offer will be accepted. This card is the property of ViiV Healthcare and must be returned upon request.
To the Pharmacist:
Please submit the amount of copay authorized by the patient’s primary insurance as a secondary transaction to McKesson Corporation. By redeeming this coupon, I certify that: (i) I have received this coupon from an eligible patient, (ii) I have dispensed the product as indicated, (iii) I have not submitted, and will not submit, a claim for reimbursement to the patient or any federal, state, or other governmental payer or to any Medicare Part D Plan, (iv) I have not retained or provided to any person or entity any portion of the amount being made available to the patient, and (v) I will otherwise comply with the terms hereof. I further certify that my participation in this program is consistent with all applicable state laws and any obligations, contractual or otherwise, that I have as a pharmacy provider. It is a violation of federal law to buy, sell, or counterfeit this card.
To the Healthcare Professional:
If you are a healthcare professional who resides outside the state of Vermont but regularly practices in Vermont, please do not download, print, or otherwise accept coupons or vouchers for ViiV Healthcare products.