To be eligible for the Free Trial Offer:
TO THE PATIENT: You may use this Free Trial Offer only for free product. That is, in order to be eligible for this offer, this Free Trial Offer must be accompanied by a valid, signed prescription. Further, you are NOT eligible for this offer if either: (a) 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, or under any private insurance, HMO, or other third-party payment arrangement, or (b) any part of this prescription will be submitted to count toward your out-of-pocket cost under your prescription drug plan, such as the ?True Out-Of-Pocket (TrOOP)? expenses under Medicare Part D. Only an original Free Trial Offer will be accepted and must be presented to your pharmacist at the time you have your prescription filled?not valid if reproduced.
By tendering this Free Trial Offer, I, the Patient, certify that: (i) I have read the above terms, (ii) I am not being reimbursed by, nor will I submit a claim for reimbursement by, nor will I seek to have any portion of this prescription counted toward my out-of-pocket cost (eg, TrOOP) under, any federal, state, or private programs for this prescription, and (iii) I will otherwise comply with the terms above.
Mail-order: If you use a mail-order pharmacy, please contact your pharmacy provider to ensure this offer will be accepted.
TO THE PATIENT AND PHARMACIST: Offer good only in USA, including Puerto Rico. Void where prohibited by law, taxed, or restricted. Not valid in Massachusetts if AB-rated generic drug is available for the product. No purchase required. May not be used with any other discount, Free Trial Offer, or offer. GSK and McKesson (on GSK's behalf) reserve the right to rescind, revoke, or amend this Free Trial Offer without notice. This Free Trial Offer is nontransferable. Duplicates of this uniquely coded Free Trial Offer are invalid and not redeemable at the pharmacy.
This Free Trial Offer is the property of GSK and must be returned upon request.