Patient Eligibility

PATIENT:In order to be eligible for this offer:

• Where third-party reimbursment covers a portion of your prescription, this coupon is valid only for the amount of your actual out-of-pocket expenses up to a maximum of $10.00,
• Your prescription MUST NOT be covered (ie, reimbursed) by a federal healthcare program, including Medicare or Medicaid, or by any similar federal or state program, including a state pharmaceutical assistance program, and
• You MUST NOT be Medicare eligible and enrolled in an employer-sponsored health plan / prescription drug benefit program for retirees (ie, you are eligible for Medicare Part D but receive a prescription drug benefit through a former employer).
• Further, if you are a resident of Massachusetts, this offer is valid only if you are paying the entire cost of the prescription yourself (ie, your insurance does not cover any of the cost of your prescription).

Your acceptance of this offer must be consistent with the terms of any drug benefit provided by your health insurer, health plan, or private third-party payor, and you agree to report acceptance of this offer to your health insurer, health plan, or third-party payor as may be required.

This offer may not be used with any other discount, coupon or offer. Only an original coupon will be accepted and must be presented to your pharmacist at the time you have the prescription filled—not valid if reproduced. Offer good only in the USA. Not transferable. Void where prohibited by law, taxed or restricted. GlaxoSmithKline reserves the right to discontinue this offer at any time.
Limit 1 per purchase.

By tendering this coupon, I, the Patient, certify that: (i) I have read the above terms, (ii) I will not submit a claim for reimbursement under any federal, state, or other governmental programs for this prescription, (iii) if I am Medicare eligible, I am not enrolled in an employer-sponsored health plan or prescription drug plan for retirees, and (iv) I will otherwise comply with the terms above.