Please see Important Safety Information below.

Patient:

In order to be eligible for this offer: (a) where third-party reimbursement covers a portion of your prescription, this coupon is valid only for the amount of your actual out-of-pocket expenses up to a maximum of $50, (b) your prescription MUST NOT be covered and/or reimbursed by a federal healthcare program, including Medicare or Medicaid, or by any similar federal or state program, including a state pharmaceutical assistance program, and (c) you MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees (i.e., you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer). Further, if you are a resident of Massachusetts, this offer is valid only if you are paying the entire cost of the prescription yourself (i.e., your insurance does not cover any of the cost of your prescription). Your acceptance of this offer must be consistent with the terms of any drug benefit provided by your health insurer, health plan, or private third-party payor, and you agree to report acceptance of this offer to your health insurer, health plan, or third-party payor as may be required. This offer may not be used with any other discount, coupon, or offer. Only an original coupon will be accepted and must be presented to your pharmacist at the time you have the prescription filled not valid if reproduced. Offer good only in USA. Not transferable. Void where prohibited by law, taxed, or restricted. GlaxoSmithKline reserves the right to rescind, revoke, or amend this coupon without notice. Limit 1 per purchase. Only one $50 trial coupon per person.

By tendering this coupon, I, the Patient, certify that: (i) I have read the above terms, (ii) I will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription, (iii) if I am Medicare eligible, I am not enrolled in an employer-sponsored health plan or prescription drug plan for retirees, and (iv) I will otherwise comply with the terms above.

Pharmacist:

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 payor, and (iv) 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.

Please dispense TREXIMET at up to a $50 discounted price off the patient's out-of-pocket expense. This claim may be submitted electronically through McKesson using the information on the first page. Submit all claims in NCPDP standard 5.1. Secondary processing should follow NCPDP standards for Copay Only billing (other coverage code "8"), or Coordination of Benefits processing, dependent on your pharmacy software requirements. Call the McKesson help desk at 1-866-747-1170 for processing questions. Hours of Operation are Monday-Friday 8am-9pm and Saturday 9:30am-6pm ET, excluding holidays. Restore patient's profile to Primary PBM, if appropriate, after claim submission.