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I have read, understood and consented to the declaration as provided. Annual Fee one-time : Rs. Back Fuel Surcharge waiver Maximum surcharge waiver of Rs. Simply wave your card at a secure reader and your transaction is done.

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Security: During a transaction the card never leaves your hand; significantly reducing the risk of card loss and fraud due to counterfeit skimming. Even if the card is waved multiple times at the reader, the unique security key feature of Visa payWave will ensure that only one transaction goes through, thus making it more secure. Patients may not use this offer if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. This offer is not valid for cash-paying patients.

Each card is valid for up to twelve 12 prescription fills of a day supply each OR up to six 6 prescription fills of a day supply each OR up to four 4 prescription fills of a day supply each. Allergan reserves the right to rescind, revoke, or amend this offer without notice. Void where prohibited by law, taxed, or restricted. This card is not transferable.

The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.

This card has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. This offer is not health insurance.


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This card expires December 31, By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer. For questions about the program, including savings on mail-order prescriptions, please call 1. Pharmacist Instructions for a Patient with an Eligible Third-party Payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription.

Reimbursement will be received from Change Healthcare. For any questions regarding online processing, call the Help Desk at 1. Participation is subject to certain limitations and restrictions. Please review the full Terms, Conditions, and Eligibility Criteria below. Based on the information you have provided, you are not eligible to participate in this program. Thank you for your interest.

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