
Offer not valid for prescriptions reimbursed under Medicaid, a Medicare drug benefit plan or other federal or state programs (such as medical assistance programs). If you are eligible for drug benefits under any such program, you cannot receive this rebate. By submitting this rebate voucher, you agree that you will not submit a claim for the prescription to a government payor.
If any part of your prescription is paid for by a non-governmental third party payor, you attest to having disclosed this offer to your third party payor.
This certificate must be accompanied by an original dated cash register pharmacy receipt for TRAVATAN Z® Solution (proof of purchase) and empty 2.5 mL or 5 mL carton. Make a copy of your submission for your records.
Offer applies to out of pocket expenses for TRAVATAN Z® Solution of more than $20.00.
Out of pocket expenses greater than $20.00 will be reimbursed up to a maximum $25.00 of actual out of pocket expense.
This original certificate and the original proof of purchase may not be reproduced and must accompany the request.
Rebate materials will not be returned.
Offer not extended to clubs, groups, or organizations.
Offer good only in the U.S.A. Void where taxed, restricted or prohibited by law.
Please allow 8 to 10 weeks for delivery. Not responsible for lost or stolen checks.
Offer expires 9/15/09.
Request must be postmarked by 9/30/09.
Fraudulent submission of multiple requests could result in federal prosecution under the U.S. Mail Fraud Statutes (18 USC, Sections 1341 and 1342).
Incomplete or illegible requests will not be honored. Not responsible for lost, mutilated, misdirected or postage-due mail and/or requests.
By submitting this voucher you acknowledge that you understand and have complied with the rules of this offer.
Sponsor: Alcon, Inc., 6201 South Freeway, Fort Worth, Texas 76134.