Program Terms, Conditions, and Eligibility Criteria:
This offer is good for use only with a valid prescription for ESTRACE® CREAM (estradiol vaginal
cream, USP, 0.01%) at the time the prescription is filled by the pharmacist and dispensed to the
Depending on your insurance coverage, most eligible patients pay as little as $10 for each of up
to 4 prescription fills of one (1) 42.5 g tube of brand-name ESTRACE® CREAM each.
Check with your pharmacist for your copay discount.
Maximum savings limit applies; patient out-of-pocket expense will vary.
This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other
federal or state programs (including any state pharmaceutical assistance programs), or
private indemnity or HMO insurance plans that reimburse you for the entire cost of
your prescription drugs. Patients may not use this offer if they are Medicare-eligible
and enrolled in an employer-sponsored health plan or prescription drug benefit program
for retirees. This offer is not valid for cash-paying patients.
Each card is valid for up to four (4) prescription fills of one 42.5 g tube of ESTRACE®
CREAM each. Offer applies only to prescriptions filled before the program expires on 12/31/18.
Allergan reserves the right to rescind, revoke, or amend this offer without notice.
Offer good only in the USA, including Puerto Rico, at participating retail pharmacies.
Void if prohibited by law, taxed, or restricted.
This card is not transferable. The selling, purchasing, trading, or counterfeiting of
this card is prohibited by law.
This card has no cash value and may not be used in combination with any other discount,
coupon, rebate, free trial, or similar offer for the specified prescription.
This offer is not health insurance.
This card expires December 31, 2018.
By redeeming this card, you acknowledge that you are an eligible patient and that you
understand and agree to comply with the terms and conditions of this offer.
For questions about the program, including savings on mail-order prescriptions,
please call 1.855.439.2814.
Pharmacist Instructions for a Patient with an Eligible
When you redeem this card, you certify that you have not submitted and will not submit a
claim for reimbursement under any federal, state, or other government programs for this
Submit the claim to the primary Third Party Payer first, then submit the balance due to Change Healthcare
using BIN #004682 as a Secondary Payer COB with patient responsibility amount and a
valid Other Coverage Code (e.g., 8). The patient’s out-of-pocket expense will be reduced up to
the maximum savings limit for the program. Reimbursement will be received from Change Healthcare.
For any questions regarding Change Healthcare online processing, call the Help Desk at 1.800.422.5604.
Program managed by ConnectiveRx on behalf of Allergan.