SAVE UP TO to $20 off on each of up to 6 eligible FORADIL® AEROLIZER® (formoterol fumarate inhalation powder) prescriptions

Don't forget to print and pick up your coupon from the printer. If you lose the coupon, please print out another coupon from foradil.us. Regardless of the number of replacement coupons printed, the coupon offer is limited to 6 prescriptions for FORADIL AEROLIZER per patient prior to the expiration date of this program. Coupon must accompany a valid signed prescription. Restrictions apply. Please see full terms and conditions on coupon.

This coupon is not insurance.

Eligible patients may save up to $20 off on each of up to 6 qualifying prescriptions for FORADIL AEROLIZER.

FORADIL AEROLIZER is a prescription medication. Only your health care provider can decide if FORADIL AEROLIZER is right for you.

How this coupon works:

• This coupon can be used up to 6 times before the expiration date and provides a maximum benefit of up to $20 or the amount of your copay, whichever is less, off on each of up to 6 qualifying prescriptions.
• To receive up to $20 in savings on your out-of-pocket cost for FORADIL AEROLIZER present this coupon and your insurance card (if any) with a valid signed prescription at any participating eligible retail or mail-order pharmacy (certain restrictions apply).
• If you are unable to redeem this coupon at your eligible retail or mail-order pharmacy, please keep your receipt and call McKesson Corporation at 877-264-2440 within 30 days of purchase to request a Direct Member Reimbursement (DMR) form.
• If you lose this coupon, please print out another coupon from foradil.us. Regardless of the number of replacement coupons printed, this coupon offer is limited to 6 prescriptions for FORADIL AEROLIZER per patient prior to the expiration date of this program.
• No other purchase is necessary. Restrictions apply. Please see Terms and Conditions.

Prescriber

To initiate a coupon for an appropriate patient to use up to 6 times, you should:

• Read the Prescribing Information before prescribing FORADIL AEROLIZER.
• Write a prescription for FORADIL AEROLIZER. No substitutions are permitted.
• Give the signed prescription and this coupon to the patient along with the Patient Information for FORADIL AEROLIZER.
• Eligible patients can take this coupon and the signed prescription to any participating eligible retail or mail-order pharmacy to receive savings on their out-of-pocket cost (depending on their copay).
• For additional copies of the Prescribing Information, call 800-672-6372, visit foradil.us, or contact your Merck representative.
• Not all patients are eligible to use this coupon. Please see Terms and Conditions.

Pharmacist

• Coupon is valid only when accompanied by a prescription for FORADIL AEROLIZER. Coupon value may not exceed actual copay or $20, whichever is less. Please review Terms and Conditions on coupon for important eligibility restrictions.
• Submit transaction to McKesson Corporation using BIN No. 610524.
• If primary coverage exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response. For cash-paying patients, Pharmacist agrees to charge not more than the usual and customary retail price.
• For all other prescriptions, please use the patient's primary method of payment and a new Rx number. Please clear COB secondary screen after processing transaction.
• Acceptance of this coupon and your 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, you agree that FORADIL AEROLIZER was dispensed pursuant to this coupon and that you will not submit a claim for reimbursement to Medicaid, Medicare, or any other state, federal, or other government program. You also agree not to submit any claim for reimbursement to any third-party payer who reimburses or pays any part of the prescription price or otherwise provides coverage for FORADIL AEROLIZER for Massachusetts residents.
• You agree to notify the patient's insurance carrier of this coupon redemption, as may be required by the Terms and Conditions of your 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 877-264-2440 (8 AM–8 PM ET, Monday–Friday).

Terms and Conditions

• This coupon is valid for up to $20 off each of up to 6 qualifying prescriptions for FORADIL AEROLIZER.
• Limit 6 uses per patient for the duration of the program. Patient must have a copayment or make full cash payment for the prescription. Savings are limited to amount of copay or cash payment, up to a maximum of $20 per prescription for up to 6 qualifying prescriptions.
• No other purchase is necessary.
• This coupon is not transferable. No substitutions are permitted. Cannot be combined with any other card, free trial, discount, prescription savings card, or other offer.
• This coupon is not insurance.
• This coupon is valid for patients with private insurance or cash-paying 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 FORADIL AEROLIZER.
• You must be 18 years or older to redeem this coupon for yourself or your minor child. Patient, guardian, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the recipient through this offer. Patient or guardian 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 this coupon, as may be required.
• This coupon can be used only by eligible US or Commonwealth of Puerto Rico residents 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.
• 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 if reproduced. Void where prohibited by law, taxed, or restricted.
• Merck reserves the right to rescind, revoke, or amend this offer at any time without notice.
• Please read the accompanying Medication Guide and discuss it with your doctor.
• Expiration Date: 12/31/2012.

Regardless of how many coupons you print, you may only use the coupons, and receive up to $20 off on an eligible prescription, a total of 6 times before the expiration date printed on the coupons.

Copyright ® 2011, Schering Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ 07033.

All rights reserved.

RESP-1005724-0000 06/11