#Doctor discharge letter template trial#
The ELIQUIS Free 30-Day Trial offer is not health insurance.This Free 30-Day Trial card may not be sold, purchased, traded, or counterfeited.Activation and use of the Free 30-Day Trial card must take place by December 31, 2024.
Patients may not count the Free 30-Day Trial of ELIQUIS as an expense incurred for purposes of determining out-of-pocket costs for any plan, including true out-of-pocket costs, (TrOOP), for purposes of calculating the out-of-pocket threshold for Medicare Part D plans.Patients, pharmacists, and prescribers cannot seek reimbursement for the Free 30-Day Trial of ELIQUIS from health insurance or any third party, including state or federally funded programs.The Free 30-Day Trial for the specified prescription cannot be combined with any other rebate/coupon, free trial, or similar offer.By redeeming this offer, you certify that you have not previously filled a prescription for ELIQUIS. This offer is limited to one use per patient per lifetime and is non-transferable.
This offer may not be redeemed on prescriptions written for longer than 30 days. Patient is responsible for applicable taxes, if any.
Box 2914, Phoenix, AZ, 85062-2914.īY USING THIS CARD, YOU AND YOUR PHARMACIST UNDERSTAND AND AGREE TO COMPLY WITH THESE ELIGIBILITY REQUIREMENTS AND TERMS OF USE. Questions can also be submitted via mail to: P.O.
#Doctor discharge letter template download#
For those customers using mail order or any non-participating retail pharmacy, please call 86 to request a patient rebate form, or go to to download a form. The Co-pay Card will be accepted only at participating pharmacies. The Co-pay Card for ELIQUIS is not health insurance.This offer is not conditioned on any past, present, or future purchase, including refills.Bristol Myers Squibb and Pfizer reserve the right to rescind, revoke, or amend this offer at any time without notice.Reproductions of this Co-pay Card are void. The Co-pay Card may not be sold, purchased, traded, or counterfeited.This offer is non-transferable, no substitutions are permissible, and offer cannot be combined with any other rebate/coupon, free trial, or similar offer for the specified prescription.Territories this offer is void where restricted or prohibited by law. Only valid in the United States, Puerto Rico, or other select U.S.All Program payments are for the benefit of the patient only.Upon expiration, eligible patients may re-enroll in the Co-pay Card Program. Activation and first use of the Co-pay Card must take place by December 31, 2024. Your acceptance of this offer confirms that this offer is consistent with your insurance and that you will report the value received as may be required by your insurance provider.Patients, pharmacists, and prescribers cannot seek reimbursement, from health insurance or any third party, for any part of the benefit received by the patient through this offer.Offer not applicable to co-pays of $10 or less.Eligible patients who present an activated Co-pay Card together with a valid prescription for ELIQUIS at participating pharmacies may pay as little as $10 per 30-day supply (up to 74 tablets for the first fill and up to 60 tablets for all subsequent fills) for up to 24 months, subject to a maximum annual benefit of $6400.
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