Microsoft word - lipitorcard.doc

LIPITOR for Less than the Average Cost
of a Generic Statin††

Get the #1 prescribed branded cholesterol-lowering medicine in the world† for as low as a $4.00 co-pay.* Terms and conditions apply, see below. If you're an eligible patient, simply use the LIPITOR Co-Pay Card every time you fill your prescription for LIPITOR to instantly start saving. • $54 or less, you pay only $4 • $55 or more, save $50 off your monthly cost, up to $600 of savings per This program is available at participating pharmacies
Co-Pay Card Terms and Conditions
By using the LIPITOR $4 Co-Pay Card (the “Card”), you acknowledge that you currently meet the eligibility criteria and will comply with the terms & conditions described below: This Card is not valid for prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare or other federal or state healthcare programs (including any state prescription drug assistance programs and the Government Health Insurance Plan available in Puerto Rico [formerly known as “La Reforma de Salud”]). The Card is not valid for prescriptions that are eligible to be reimbursed by private insurance plans or other health or pharmacy benefit programs which reimburse you for the entire cost of your prescription drugs. To qualify for this offer, your out-of-pocket expense must be greater than $4 per prescription. If your out-of-pocket expenses for a 1-month supply (30 tablets) are $54 or less, you will pay $4 for a 1-month supply. If your out-of-pocket expenses for a 1-month supply (30 tablets) exceed $54, you qualify for up to $50 in savings for a 1-month supply. In either case, you can only qualify for up to $600 of savings per calendar year. After maximum of $600, you will pay usual monthly out-of-pocket costs. or call 1-800-894-1013
You must deduct the value received under this program from any reimbursement request submitted to your insurance plan, either directly by you or on your behalf. The Card is not valid for Massachusetts residents whose prescriptions are covered in whole or in part by third-party insurance, or where otherwise prohibited by law. This Card cannot be combined with any other rebate/coupon, free trial or similar offer for the specified prescription. The Card will be accepted only at participating pharmacies.
This Card is not health insurance.
Offer good only in the U.S. and Puerto Rico. The Card is limited to 1 per person during this offering period and is not transferable. Offer limited to 1 use per month. Pfizer reserves the right to rescind, revoke or amend the program without notice at any time. For reimbursement when using a non-participating pharmacy/mail order: Pay for LIPITOR prescription and mail copy of original pharmacy receipt (cash register receipt NOT valid) with product name, date and amount circled to: LIPITOR Co-Pay Card 6501 Weston Parkway, Suite 370 Cary, NC 27513 Be sure to include a copy of the front of your Co-Pay Card, your name and mailing address. ††IMS Transaction Copay Data 3/1/2010-8/31/2010. - Start the 12-week guide to managing cholesterol



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