MOST COMMERCIALLY INSURED PATIENTS

PAY AS LITTLE AS $25*

On each of your applicators for these Perrigo ® Products


You can save up to $75 on each of your applicators of Clindesse or Gynazole•*. Fill out the following form below to see if you are eligible. See below for Terms and Conditions. Certain restrictions apply.


*Eligible patients will pay the first $25 and receive up to $75 off the patient’s co-pay or out-of-pocket expenses on each applicator.


Please see full prescribing information for Clindesse and Gynazole•.


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TERMS AND CONDITIONS
Patient Instructions: In order to redeem this offer you must have a valid prescription for Clindesse or Gynazole•1. Follow the dosage instructions given by the doctor. This offer may not be redeemed for cash. By using this offer, you are certifying that you meet the eligibility criteria and will comply with the terms and conditions described in the Restrictions section below. Patients with questions about the offer should call 1-844-492-9820.

Pharmacist: When you apply this offer, you are certifying that you have not submitted a claim for reimbursement under any federal, state, or other governmental programs for this prescription. Participation in this program must comply with all applicable laws and regulations as a pharmacy provider. By participating in this program, you are certifying that you will comply with the terms and conditions described in the Restrictions section below.

Pharmacist instructions for a patient with an Eligible Third Party Payer: Submit the claim to the primary Third Party Payer first, then submit the balance due to CHANGE HEALTHCARE as a Secondary Payer COB [coordination of benefits] with patient responsibility amount and a valid Other Coverage Code, (e.g. 8). The patient is responsible for the first $25 and the card pays up to the next $75 on each applicator. The patient is responsible for any remaining balance. Reimbursement will be received from CHANGE HEALTHCARE .

Pharmacist instructions for a cash-paying patient: Submit this claim to CHANGE HEALTHCARE . A valid Other Coverage Code (e.g. 1) is required. The patient is responsible for the first $25 and the card pays up to the next $75 on each applicator. The patient is responsible for any remaining balance. Reimbursement will be received from CHANGE HEALTHCARE .

Valid Other Coverage Code required. For any questions regarding CHANGE HEALTHCARE online processing, please call the Help Desk at 1-800-422-5604.

Restrictions: This offer is valid in the United States. Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan, Tricare or other federal or state health programs (such as medical assistance programs). If the patient is eligible for drug benefits under any such program, the patient cannot use this offer. By using this offer, the patient certifies that they will comply with any terms of their health insurance contract requiring notification to their payor of the existence and/or value of this offer. Offer not valid for patients under 18 years of age. It is illegal to (or offer to) sell, purchase, or trade this offer. This offer is not transferable and is limited to one offer per person. Not valid if reproduced. Void where prohibited by law. This is not insurance. Program managed by ConnectiveRx on behalf Perrigo Company of South Carolina, Inc. The parties reserve the right to rescind, revoke or amend this offer without notice at any time.

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