BIN No.

: 610524 RxPCN: Loy alty

Issuer: (80840)

Group No.: 40005684 ID No.: 510726981

Eligible patients may SAVE up to $20 on a qualifying prescription for SINGULAIR (montelukast sodium)
Terms and Conditions: This coupon is v alid f or up to $20 of f 1 qualif y ing prescription f or SINGULAIR. Limit 1 coupon per patient f or the duration of the program. Coupon v alid f or 1-time use only . Patient must hav e a copay ment or make f ull cash pay ment f or the prescription. Sav ings are limited to amount of copay or cash pay ment up to a maximum of $20. No other purchase is required. This coupon is not transf erable. No substitutions are permitted. Cannot be combined with any other f ree trial, discount, prescription sav ings card, or other of f er. This coupon is not insurance. This coupon is v alid f or patients with priv ate insurance or cash-pay ing patients. Not valid for patients covered under Medicaid, Medicare, a Medicare Part D or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan (Healthcare Reform), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program. This coupon is void for Massachusetts residents if a third-party payer reimburses or pays any amount of the prescription price or otherwise provides coverage for SINGULAIR. Y ou must be 18 y ears or older to redeem this coupon f or y ourself or y our minor child. Patient, guardian, pharmacist, and prescriber agree not to seek reimbursement f or all or any part of the benef it receiv ed by the recipient, through this of f er. Patient or guardian is responsible f or reporting receipt of coupon benef it to any insurer, health plan, or other third party who pay s f or or reimburses any part of the prescription f illed using this coupon, as may be required. This coupon can be used only by eligible US 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 where prohibited by law, taxed, or restricted. Merck reserv es the right to rescind, rev oke, or amend this of f er at any time without notice. Please read the Patient Inf ormation on singulair.com and discuss it with y our doctor. Also on singulair.com is the phy sician Prescribing Inf ormation. Expiration Date: 08/31/2012.

This coupon is not insurance. SINGULAIR is a prescription medication. Only y our health care prov ider can decide if SINGULAIR is right f or y ou. How this coupon works: This coupon can be used 1 time bef ore the expiration date and prov ides a maximum benef it of up to $20 or the amount of y our copay , whichev er is less. To receiv e up to $20 in sav ings on y our out-of -pocket cost f or SINGULAIR, present this coupon and y our insurance card (if any ) with a v alid signed prescription at any participating eligible retail or mail-order pharmacy (certain restrictions apply ). If y ou are unable to redeem this coupon at y our eligible retail or mailorder pharmacy , please keep y our receipt and call McKesson at 800657-7613 within 30 day s of purchase to request a Direct Member Reimbursement (DMR) f orm. No other purchase is necessary . Restrictions apply . Please see Terms and Conditions. Prescriber: To initiate a coupon for an appropriate patient, you should: Read the Prescribing Inf ormation av ailable at singulair.com bef ore prescribing SINGULAIR. Write a prescription f or SINGULAIR. No substitutions are permitted. Giv e the signed prescription and this coupon to the patient along with the Patient Inf ormation f or SINGULAIR. Eligible patients may take this coupon and the prescription to any participating eligible retail or mail-order pharmacy to receiv e sav ings on their out-of -pocket cost (depending on their copay ). Not all patients are eligible to use the coupon. Please see Terms and Conditions. Pharmacist: Coupon is v alid only when accompanied by a prescription f or SINGULAIR. Coupon v alue may not exceed actual copay or $20, whichev er is less. Please review Terms and Conditions on coupon for important eligibility restrictions. Submit transaction to McKesson Corporation, using BIN No. 610524. If primary cov erage exists, input card inf ormation as secondary cov erage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be display ed in the transaction response. For cash-pay ing patients, Pharmacist agrees to charge not more than the usual and customary retail price. For all other prescriptions, please use the patients primary method of pay ment and a new Rx number. Please clear COB secondary screen af ter processing transaction. Acceptance of this coupon and y our submission of claims are subject to the Terms and Conditions established by McKesson Corporation posted at www.mckesson.com/mprstnc and the terms and conditions of this coupon. By processing this coupon, y ou agree that SINGULAIR was dispensed pursuant to this coupon and that y ou will not submit a claim f or reimbursement to Medicaid, Medicare, or any other state, f ederal, or other gov ernment program. Y ou also agree not to submit any claim f or reimbursement to any third-party pay er who reimburses or pay s any part of the prescription price or otherwise prov ides cov erage f or SINGULAIR f or Massachusetts residents. Y ou agree to notif y the patient's insurance carrier of this coupon redemption, as may be required by the terms and conditions of y our relationship with the insurance carrier. This coupon may not be applied toward any other pharmacy purchase. For pharmacy processing questions, please call the Help Desk at 800-657-7613 (8 AM8 PM ET, MondayFriday).

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