PROPECIA® (finasteride) Promise Program
Terms and Conditions
Patient Eligibility Criteria
To qualify for this refund:
To qualify for this refund:
- You must be male.
- You must be 18 years or older.
- Your enrollment form must be postmarked by 6/1/2012.
- You must agree to receive mail, e-mail, and other information from Merck about hair loss and PROPECIA 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/programs/accreditation/vipps/find-a-vipps-online-pharmacy/.
- 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.
PROPECIA was developed to treat mild to moderate male pattern hair loss on the vertex (top of head) and anterior mid-scalp area (middle front of head) in MEN ONLY. There is not sufficient evidence that PROPECIA works for receding hairlines at the temples.
Important Risk Information About PROPECIA
PROPECIA is for the treatment of male pattern hair loss in MEN ONLY and should NOT be used by women or children.
You should not use PROPECIA if you are allergic to finasteride or any of the ingredients of PROPECIA.
Women who are or may potentially be pregnant must not use PROPECIA and should not handle crushed or broken PROPECIA tablets because the active ingredient may cause abnormalities of a male baby’s sex organs. If a woman who is pregnant comes into contact with the active ingredient in PROPECIA, a doctor should be consulted. PROPECIA tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets are not broken or crushed.
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; depression; allergic reactions including rash, itching, hives, and swelling of the lips and face; problems with ejaculation; testicular pain; difficulty in achieving an erection that continued after stopping the medication; and, in rare cases, male breast cancer. You should promptly report to your doctor any changes in your breasts such as lumps, pain, or nipple discharge. Tell your doctor promptly about these or any other unusual side effects.
PROPECIA can affect a blood test called PSA (prostate-specific antigen) for the screening of prostate cancer. If you have a PSA test done, tell your doctor that you are taking PROPECIA because PROPECIA decreases PSA levels; also tell your doctor if you have not been taking PROPECIA as prescribed because this may affect PSA test results. Any changes in PSA test results while taking PROPECIA will need to be carefully evaluated by your doctor.
Click here for access to the Prescribing Information and the Patient Product Information.
Refund Terms
You should not use PROPECIA if you are allergic to finasteride or any of the ingredients of PROPECIA.
Women who are or may potentially be pregnant must not use PROPECIA and should not handle crushed or broken PROPECIA tablets because the active ingredient may cause abnormalities of a male baby’s sex organs. If a woman who is pregnant comes into contact with the active ingredient in PROPECIA, a doctor should be consulted. PROPECIA tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets are not broken or crushed.
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; depression; allergic reactions including rash, itching, hives, and swelling of the lips and face; problems with ejaculation; testicular pain; difficulty in achieving an erection that continued after stopping the medication; and, in rare cases, male breast cancer. You should promptly report to your doctor any changes in your breasts such as lumps, pain, or nipple discharge. Tell your doctor promptly about these or any other unusual side effects.
PROPECIA can affect a blood test called PSA (prostate-specific antigen) for the screening of prostate cancer. If you have a PSA test done, tell your doctor that you are taking PROPECIA because PROPECIA decreases PSA levels; also tell your doctor if you have not been taking PROPECIA as prescribed because this may affect PSA test results. Any changes in PSA test results while taking PROPECIA will need to be carefully evaluated by your doctor.
Click here for access to the Prescribing Information and the Patient Product Information.
- 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 (eg, 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.
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, 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:
- Sign and date the form where indicated.
- 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.
- Attach your 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.
- 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 1 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.
Continue for Refund Request Form
This site is intended only for residents of the United States, its territories, and Puerto Rico.
Copyright © 2011 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved.
DERM-1015482-0000 11/11
Copyright © 2011 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved.
DERM-1015482-0000 11/11