Save up to $40.00 on EVOCLIN
Instructions for patients (with or without insurance)
The rebate applies only to a prescription for EVOCLIN. Please request that your pharmacist fill your prescription exactly as written by your physician.
If you have questions about your insurance coverage or your co-payment amount for EVOCLIN, call the ConneticsCareSM Insurance Coverage Support Program at 1-800-572-3225. To receive your rebate on your prescription, complete the information on back and mail thecoupon along with your original pharmacy receipt that shows the name EVOCLIN and the co-pay amount.
For the 50-gram canister, you will receive a rebate equal to 50% of your co-pay amount or $20.00, whichever is less; or for the 100-gram canister you will receive a rebate equal to 50% of your co-pay amount or $40.00, whichever is less, for your prescription of EVOCLIN.
Mail completed coupon and original pharmacy receipt to:
MCT Synergistics, PO Box 99, Acworth, GA 30101-0099
Connetics respects your right to have personal and medical information kept confidential. Connetics and the companies acting on the behalf of Connetics will not share any information received from you with any other party.
By my signature, I certify that I meet and agree to the terms and conditions listed on the coupon. Rebates are not valid for prescriptions reimbursed under any federal health care program, including Medicare, Medicaid, CHAMPUS/TriCare, or Department of Veterans Affairs, as well as any similar federal or state medical assistance programs. In the state of Massachusetts, rebates are valid only for residents who are solely responsible for the cost of the prescription and are not seeking nor will seek any reimbursement from any third-party payer.
The coupon may not be reproduced and must accompany the request. Offer good only in the USA, but void where prohibited by law, taxed, or restricted. Connetics reserves the right to rescind, revoke, or amend this offer without notice. Allow 2 to 4 weeks for delivery.
OFFER EXPIRES: The earlier of December 31, 2007, or 90 days from date of prescription fill.
ConneticsCare is a service mark, the "wisp" logo and the foam dollop are trademarks, and Connetics, EVOCLIN, and the interlocking "C" logo are registered trademarks of Connetics Corporation.