Your enrollment form must be postmarked by 6/1/2012.
You must agree to receive mail, e-mail, and other information from Merck about PROPECIA (finasteride) over the course of your 12 consecutive months of therapy. You may withdraw your consent to receive communication from Merck at any time, but if you withdraw your consent, you will no longer be enrolled in or be eligible to participate in the 12-Month Promise of PROPECIA.
You must purchase your prescription(s) for a minimum of 12 consecutive months (defined as the purchase of 360 tablets of PROPECIA) before 6/30/2013.
The 12-Month Promise of PROPECIA refund is valid for cash-paying patients only. Patient must make full cash or cash equivalent payment for the prescription. The 12-Month Promise of PROPECIA refund is not valid for prescriptions of PROPECIA for which you or your pharmacy or dispensing physician receive (or are eligible to receive) any reimbursement or price reduction through Medicaid, Medigap, Medicare Part D or Medicare Advantage Plan, TRICARE, CHAMPUS, VA, DOD, or similar federal or state programs, private insurance, employer-sponsored insurance, health maintenance organization (HMO), preferred provider organization (PPO), pharmacy benefits manager (PBM), or other health care programs.
You must be a resident of the United States and your prescriber must practice in the United States. Your receipts must be from an eligible pharmacy, dispensing physician, or a VIPPS®-certified pharmacy located in the United States. Product must originate in the United States.
Purchases from online pharmacies qualify for this program only if the pharmacy is VIPPS®-certified. The list of VIPPS®-certified pharmacies may be found at www.nabp.net/vipps/consumer/listall.asp.
You must not be a resident of Maine or Massachusetts.
You must submit the required documentation with the Refund Request Form as described below. No other purchase is necessary.
Refund Terms
Refund is valid for PROPECIA only. Prescriptions for PROPECIA purchased after 6/30/2013 will not qualify for a refund.
The maximum amount of any refund will be equal to the out-of-pocket cost (purchase price, less any coupons, savings, or rebates) paid for 12 consecutive months of prescriptions for PROPECIA (defined as the purchase of 360 tablets of PROPECIA), not to exceed $880.00.
Refunds will be given only if you complete 12 consecutive months of therapy and submit receipts for all 12 months of therapy.
Refund is valid for the out-of-pocket cost for 12 months of prescriptions for PROPECIA only. Refund is not valid for any other products, other out-of-pocket costs listed on your submitted receipt(s), or your prescriber visit copay.
Only the patient may request the refund. The patient's prescriber or health care professional may not request the refund on behalf of the patient and may not receive the refund directly from Merck.
By requesting a refund, you agree to forfeit your eligibility to receive rebates for any future purchases of PROPECIA. Patient is limited to one (1) refund request submission provided the patient meets eligibility requirements and the Terms and Conditions.
The Refund Request Form must be postmarked by the return date printed on the form. Refund Request Forms postmarked after the return date listed on the form will not be honored.
If the Terms and Conditions are met, the refund will be paid to the patient submitting the refund request.
All information requested on the Refund Request Form must be provided and the certifications must be signed. Forms that are not filled out completely or are modified will not be eligible for a refund. You must ensure that your prescriber completes the Prescriber Certification portion of the form.
Refund Request Form must include:
The original Refund Request Form. The form must be filled out completely and may not be modified in any manner. The form must contain original signatures.
Pharmacy receipt(s) indicating the date, the product you purchased was PROPECIA, the number of pills, and the price you paid out of pocket for PROPECIA.
Receipt(s) for all 12 consecutive months of purchases of prescriptions for PROPECIA which the patient is requesting a refund, must be submitted together, at one time, with the Refund Request Form.
If you have previously submitted to Merck or one of its program administrators (e.g. McKesson Corp.), original receipts to receive rebates for PROPECIA, you do not have to submit these receipts again.
Refund is nontransferable. No substitutions are permitted.
Refund Request Form is void if reproduced or if modified in any manner.
Refund is void where prohibited by law, taxed, or restricted.
You may not sell, purchase, trade, or counterfeit the Refund Request Form.
Patient and prescriber agree not to seek reimbursement for all or any part of the benefit(s) received by the patient through this offer.
If a coupon or savings card was used for prescriptions submitted for a refund, the pharmacy receipt(s) must clearly reflect the actual costs paid by the patient after the coupon or savings card was applied.
Refund is not health insurance or a substitute for health insurance.
The Refund Request Form is the property of Merck and must be turned in on request.
Merck reserves the right to rescind, cancel, or amend this offer at any time without notice.
Program Expiration Date: 10/1/2013.
Register now.
This program is for male patients aged 18 or older with male pattern hair loss who continue to use PROPECIA for 12 consecutive months.
If you take PROPECIA for 12 months and you do not maintain your hair on the vertex (top of head) and anterior mid-scalp (middle front of head), as determined by your prescriber, you may be eligible for a full refund of your purchase price, less any coupons, savings, or rebates received.
Refunds will be given only if you complete 12 consecutive months of therapy (defined as the purchase of 360 tablets of PROPECIA).
Your prescriber's original signature is required to verify your results and qualify you for your refund.
You must agree to receive mail, e-mail, and other information from Merck about hair loss and PROPECIA
over the course of your 12 months of therapy.
You may withdraw your consent to receive communications from Merck at any time, but if you withdraw your consent, you will no longer be enrolled in or be eligible to participate in the 12-Month Promise of PROPECIA.
If eligible, you can begin the enrollment process in the 12-Month Promise of PROPECIA program today. Not all patients are eligible. Please see Terms and Conditions. Click the continue button. A new page will appear that you can print, complete, and mail today. After you have printed this page, simply close this browser window to return to the Web site for PROPECIA.
Remember, PROPECIA is available by prescription only, so make an appointment with your doctor today.
Refund Instructions.
If you are eligible for a refund, follow these steps:
Save your original pharmacy receipt(s) for PROPECIA. Be sure your receipt(s) indicate the date,
that the product you purchased was PROPECIA, the number of pills, and the actual price you paid for
PROPECIA.
If, after 12 months, your prescriber determines that you have not maintained hair on the vertex or
anterior mid-scalp, you should contact Merck at 1-888-77-MERCK to request a Refund Request Form.
Once you receive the Refund Request Form:
1. Sign and date the form where indicated.
2. Take the form to your prescriber and have him/her sign and date the form and write his/her state
license number on the appropriate lines. It must include your prescriber's original signature. Signature
stamps are not accepted.
3. Attach your receipt(s) indicating the date, that the product you purchased was PROPECIA, the
number of pills, and the price you paid out of pocket for PROPECIA.
4. Using the provided preaddressed envelope, mail your completed form by the return date listed on
the form.
Mail your original pharmacy receipt(s) and completed Refund Request Form to:
Patient Support Services
PO Box 748
Horsham, PA 19044-9948
If you qualify, the refund check will be issued 6 to 8 weeks after we receive the Refund Request Form.
Please note that each patient is eligible for only one refund, for 12 months of PROPECIA (max 360
tablets) with the 12-Month Promise of PROPECIA program.
If you have questions regarding the refund, call us toll-free at 1-888-77-MERCK.
In order to help determine your eligibility for this program, please answer the following questions:
Are you a male?
YesNo
PROPECIA is for men only. You are not eligible to participate in this program.
Are you 18 years of age or older?
YesNo
You must be 18 years of age or older to use this coupon. You are not eligible to participate in this program.
Are you a resident of the United States or the Commonwealth of Puerto Rico?
YesNo
This coupon is valid only for residents of the United States and the Commonwealth of Puerto Rico. You are not eligible to participate in this program.
In which state do you reside?
The coupon is not valid for residents of Massachusetts. You are not eligible to participate in this program.
Do you or your pharmacy or dispensing physician receive (or are eligible to receive) any reimbursement or price reduction through Medicaid,
Medigap, Medicare Part D or Medicare Advantage Plan, TRICARE, CHAMPUS, VA, DOD, Puerto Rico Government Health Insurance Plan
("Healthcare Reform"), or similar federal or state programs, private insurance, employer sponsored insurance, health maintenance organization
(HMO), preferred provider organization (PPO), pharmacy benefits manager (PBM), or other health care programs for prescriptions of PROPECIA?
YesNo
The coupon is not valid for prescriptions of PROPECIA for which you or your pharmacy or dispensing physician receive (or are eligible to receive)
any reimbursement or price reduction through Medicaid, Medigap, Medicare Part D or Medicare Advantage Plan, TRICARE, CHAMPUS, VA, DOD,
Puerto Rico Government Health Insurance Plan ("Healthcare Reform"), or similar federal or state programs, private insurance, employer sponsored
insurance, health maintenance organization (HMO), preferred provider organization (PPO), pharmacy benefits manager (PBM), or other health care
programs.
If you or your pharmacy or dispensing physician begin to have coverage for your prescriptions of PROPECIA for any reimbursement or price
reduction through Medicaid, Medigap, Medicare Part D or Medicare Advantage Plan, TRICARE, CHAMPUS, VA, DOD, Puerto Rico Government
Health Insurance Plan ("Healthcare Reform"), or similar federal or state programs, private insurance, employer sponsored insurance,
health maintenance organization (HMO), preferred provider organization (PPO), pharmacy benefits manager (PBM), or other health care
programs at any time, or are or become a resident of Massachusetts, you will no longer be eligible to participate in this program.
Do you acknowledge agreement with this statement?
YesNo
Based on the information provided, you are not eligible to participate in this program.
If eligible, follow these steps to save up to $50 on an eligible prescription for PROPECIA.
The coupon is not insurance. Not all patients are eligible. Please see full Coupon Terms and Conditions below.
If your doctor thinks that PROPECIA is right for you, he or she will write a prescription for PROPECIA.
Print the coupon.
To receive up to $50 in savings on your out-of-pocket cost for PROPECIA, present this coupon with a valid signed
prescription at any participating eligible retail pharmacy (certain restrictions apply). Mail-order pharmacies are not
eligible. Online pharmacies must be VIPPS®-accredited. The list of VIPPS®-accredited pharmacies can be found at
http://www.awarerx.org/get-informed/safe-acquisition/recommended-vipps-online-pharmacies. Product must originate and be dispensed in the United States.
If you purchase PROPECIA directly from a dispensing physician, or a VIPPS®-accredited online pharmacy, or if your pharmacy does not accept the
coupon, call McKesson at 877-264-2440 and request a Direct Member Reimbursement (DMR) form. Complete the DMR form and mail
it with your original receipt to McKesson at PO Box 2914, Phoenix, AZ 85062-2914. Please note not all patients are eligible
for Direct Member Reimbursement. Physicians and online pharmacies may not redeem or process coupons.
The coupon is valid only for brand name PROPECIA (finasteride) and is not valid for the generic version of PROPECIA.
Terms and Conditions
Prescriptions for less than 90 days are not eligible for savings.
This coupon is valid for up to $50 off 1 qualifying prescription for PROPECIA.
Limit 1 coupon per patient per 90 days.
Coupon is valid for 1-time use only.
No other purchase is necessary.
The coupon is valid for cash-paying patients only. Patient must make full cash payment for the prescription.
Savings are limited to amount of your out-of-pocket cost, up to a maximum of $50.
The coupon is not valid for prescriptions of PROPECIA for which you or your pharmacy or dispensing physician receive
(or are eligible to receive) any reimbursement or price reduction through Medicaid, Medigap, Medicare Part D or Medicare
Advantage Plan, TRICARE, CHAMPUS, VA, DOD, Puerto Rico Government Health Insurance Plan ("Healthcare Reform"), or similar
federal or state programs, private insurance, employer sponsored insurance, health maintenance organization (HMO),
preferred provider organization (PPO), pharmacy benefits manager (PBM), or other health care programs. This coupon is not
valid for Massachusetts residents.
This coupon is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial,
discount, prescription savings card, or other offer.
This coupon is not insurance.
This coupon is valid for MEN ONLY.
You must be 18 years of age or older to redeem this coupon.
Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the
patient through this offer. No insurer or third party may pay for or reimburse any part of the prescription filled with
this coupon.
This coupon can be used only by eligible United States or Commonwealth of Puerto Rico residents at any participating
eligible retail or mail-order pharmacy in the United States or the Commonwealth of Puerto Rico. Product must originate in
the United States or the Commonwealth of Puerto Rico.
This coupon is the property of Merck and must be turned in on request.
It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit this coupon.
Void if reproduced. Void where prohibited by law, taxed, or restricted.
Merck reserves the right to rescind, revoke, or amend this offer at any time without notice.
Please read the Patient Information available on propecia.com and discuss it with your doctor.
Expiration Date: 9/30/2013
DERM-1070668-0000 02/13
Finasteride 1 mg is the Only FDA-Approved Pill Proven to Treat Male Pattern Hair Loss on the Vertex (Top of Head) and Anterior Mid-Scalp Area.
Prescribing & Patient Product Information
The Prescribing & Patient Product Information are also Available as PDF Downloads.
To view PDF documents, you must have the Adobe Reader installed on your computer.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.
Important Risk Information About PROPECIA (continued)
You should not use PROPECIA if you are allergic to finasteride or any of the ingredients of PROPECIA.
In clinical studies for PROPECIA, a small number of men experienced certain sexual side effects, such as less desire for sex, difficulty in achieving an erection, or a decrease in the amount of semen. Each of these side effects occurred in less than 2% of men and went away in men who stopped taking PROPECIA because of them.
In general use, the following have been reported: breast tenderness and enlargement (tell your doctor about any changes in your breasts such as lumps, pain, or nipple discharge); depression; decrease in sex drive that continued after stopping the medication; allergic reactions including rash, itching, hives, and swelling of the lips and face; problems with ejaculation that continued after stopping medication; testicular pain; difficulty in achieving an erection that continued after stopping the medication; male infertility and/or poor quality of semen; and, in rare cases, male breast cancer. Tell your doctor if you have any side effect that bothers you or that does not go away.
PROPECIA can affect a blood test called PSA (Prostate-Specific Antigen) for the screening of prostate cancer. If you have a PSA test done, you should tell your health care provider that you are taking PROPECIA because PROPECIA decreases PSA levels. Changes in PSA levels will need to be evaluated by your health care provider. Any increase in follow-up PSA levels from their lowest point may signal the presence of prostate cancer and should be evaluated, even if the test results are still within the normal range for men not taking PROPECIA. You should also tell your health care provider if you have not been taking PROPECIA as prescribed because this may affect the PSA test results. For more information, talk to your health care provider. There may be an increased risk of a more serious form of prostate cancer in men taking finasteride at 5 times the dose of PROPECIA.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.
This site is intended only for residents of the United States, its territories, and Puerto Rico.
DERM-1070668-0000 02/13
Know the facts. PROPECIA is available by prescription only, so the best thing to do is talk with your doctor.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. PROPECIA is a registered trademark of Merck Sharp & Dohme Corp. a subsidiary of Merck & Co., Inc.
