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Mail Order Rebate Form - BRILINTA
HOW TO RECEIVE THE REBATE FOR MAIL-ORDER PRESCRIPTIONS FOR YOUR BRILINTA 60-MG OR 90-MG TABLETS FOLLOW THESE SIMPLE STEPS Please read the Medication Guide and full Prescribing Information, including Boxed WARNINGS for BRILINTA 60-mg and 90-mg tablets, at www.BRILINTAPI.com
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YOUR ELIGIBLE PATIENTS CAN SAVE ON THEIR …
www.brilinta.comCOMMERCIALLY INSURED PATIENTS EACH MONTH ONE MONTH FREE* (up to 60 tablets) MEDICARE PART D AND MEDICAID PATIENTS CASH-PAYING PATIENTS Pharmacist Instructions for a Patient with an Eligible Third Party: For Commercially Insured/Covered Patients: Submit the claim to the primary Third-Party Payer first, then submit the balance due …
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