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Your Eligibility for the XOPENEX HFA® (levalbuterol tartrate) Inhalation Aerosol $20 Off Coupon

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Are you a resident of the United States or Puerto Rico?
Yes    No

Which state do you reside in?

Are you enrolled in any government, state or federally funded medical or prescription benefit program? This includes Medicare, Medicaid, Medigap, VA, DOD and TriCare as well as any other state or federal employee benefit programs?
Yes    No

Your card is not valid for prescriptions purchased under Medicaid, Medicare or similar federal, state or other government-funded benefit programs. Should you begin receiving prescription benefits from such a federal, state or government-funded program at any time, you will no longer be eligible to participate in this program. We may contact you by phone or mail periodically in order to verify that your eligibility for the program has not changed.

Do you acknowledge your agreement with the above statement?
Yes    No



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