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The personal information that you supply on this form will be used only for the purpose of the reimbursement request and inquiries and may be disclosed to third parties acting on behalf of the manufacturer to support this.

Terms and Conditions
This offer is valid only for those with commercial insurance. Offer not valid under Medicare, Medicaid or any other federal or state program, for cash-paying patients, where product is not covered by patient’s commercial insurance, or where plan reimburses you for the entire cost of your prescription drug. Offer is not valid where prohibited by law. Valid only in the US and Puerto Rico. This program is not health insurance. Offer may not be combined with any other rebate, coupon, or offer. Manufacturer reserves the right to rescind, revoke or amend the program without notice. Patient certifies responsibility for complying with applicable limitations, if any, of any commercial insurance and reporting receipt of program rewards, if necessary, to any commercial insurer. This offer expires December 31, 2019. Additional Terms and Conditions may apply.