*Field is required.
Please see additional Patient Eligibility Details and
Restrictions on the Patient Savings Card printout.
Restrictions may apply.✝
*Eligibility and restrictions: 1.
Limitations apply. 2. Valid only for those with commercial
insurance 3. Not valid if prescriptions are paid in part or in
full by any state or federally-funded healthcare program. 4.
Not valid for cash-paying patients who have no commercial
insurance or where plan reimburses you for the entire cost of
your prescription drug. 5. Offer is not valid where prohibited
by law. 6. Valid only for residents of the US and Puerto Rico.
7. This program is not health insurance. 8. Offer may not be
combined with any other rebate, coupon, or offer. 9. This card
is the property of PharmaDerm, a division of Fougera
Pharmaceuticals Inc. and must be returned upon request. 10.
Fougera reserves the right to rescind, revoke, or amend the
program without notice. 11. Patient certifies responsibility
for complying with applicable limitations, if any, or any
commercial insurance and reporting receipt of program rewards,
if necessary, to any commercial insurer. 12. Acceptance of
this card and your submission of claims for the PharmaDerm
RxSaver Program are subject to the LoyaltyScript®
program Terms and Conditions established by McKesson
Corporation. 13. This card has no cash value. 14. This Offer
expires on December 31, 2018. For any questions
regarding set up, claims transmission, patient eligibility or
other issues, call the PharmaDerm RxSaver Program at
1-844-396-8097 (8am-8pm ET, Monday-Friday).