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Pay $1/tablet* if you are:
An
eligible, privately insured patient with an
out‑of‑pocket cost of $150 or
less for a 30‑tablet supply of BELSOMRA.
Valid for
up to 12 qualifying prescriptions.
*Maximum
program savings is $2,800.
Pay $3/tablet* if you are:
An
eligible, privately insured patient with an
out‑of‑pocket cost greater than
$150 for a 30‑tablet supply of BELSOMRA.
Valid for
up to 12 qualifying prescriptions.
*Maximum
program savings is $2,800.
Notice to Qualified Health Plans:
After careful consideration and deliberation, including
analysis of the October 30, 2013, and February 6, 2014, letters
from former Secretary Sebelius to Representative McDermott
(D‑WA) and Senator Grassley (R‑IA), respectively,
Merck has decided to make a co-payment assistance program for
this Product available to enrollees of a health insurance
exchange established by a state government or the federal
government who are not eligible for Medicaid. The terms and
conditions of our patient co-payment assistance program are set
forth below.
STEP 1: Select the appropriate option:
STEP 2: Review and accept the Terms and Conditions of the coupon:
- The coupon is valid for up to 12 qualifying prescriptions for BELSOMRA. Patient is responsible for the first $30 (if out‑of‑pocket cost is $150 or less) or $90 (if out‑of‑pocket cost is greater than $150) of out‑of‑pocket cost on each prescription. Maximum total benefit is $2,800 per patient.
- The coupon is valid for use 12 times only. Patient must have a co-payment (or, if privately insured without coverage for BELSOMRA make full cash payment) for the prescription. Savings are limited to amount of your out‑of ‑pocket cost over $30 or $90 per prescription, for up to 12 qualifying prescriptions, up to a maximum total benefit of $2,800 per patient.
- The coupon can only be used for up to 30 tablets per prescription fill.
- No other purchase is necessary.
- The coupon is not transferable. No substitutions are permitted. The offer cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer.
- The coupon is not insurance.
- Patient must have private insurance. Not valid for uninsured patients or patients covered under Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange [marketplace] established by a state government or the federal government), 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 (collectively, "Government Programs").
- You must be 18 years of age or older to redeem the coupon. Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the patient through the offer. Patient is responsible for reporting receipt of coupon benefit to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription filled using the coupon, as may be required.
- The coupon can be used only by eligible residents of the United States or the Commonwealth of Puerto Rico at participating eligible retail or mail-order pharmacies in the United States or the Commonwealth of Puerto Rico. Product must originate in the United States or the Commonwealth of Puerto Rico.
- The 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 the coupon. Void if reproduced. Void where prohibited by law, taxed, or restricted.
- Merck reserves the right to rescind, revoke, or amend the offer at any time without notice.
- Data related to your redemption of the coupon may be collected, analyzed, and shared with Merck, for market research and other purposes related to assessing coupon programs. Data shared with Merck will be aggregated and de ‑identified, meaning it will be combined with data related to other coupon redemptions and will not identify you.
- Expiration Date: 03/31/2019.
STEP 3: Answer the activation questions regarding eligibility. You may be required to enter prescription insurance information, so please have the insurance card ready. Not all patients are eligible. Please see the Terms and Conditions above.
STEP 4: The activated coupon will be ready to use at an eligible pharmacy.
You must confirm that you
have read and agree to the Terms and Conditions of the coupon.
You must select an option
in Step 1 to proceed.
