Certificate for ACTOS Advantage® Program

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Here’s how to use this certificate:

• Show this certificate to your health professional.
• If you are not currently taking ACTOS, find out if ACTOS or an ACTOS combination product is right for you.
• If you receive a prescription for ACTOS or an ACTOS combination product, your health professional may be able to provide you with an ACTOS Advantage^® Program Rebate Offer, worth up to $50 off your prescription for ACTOS or an ACTOS combination product.*
• You must meet the Eligibility Requirements for participation in this program.
• ACTOS or ACTOS combination product coupons cannot be used if all or any part of your prescription is paid for by:
  • any federal or state healthcare program, including a state medical or pharmaceutical assistance program (Medicare, Medicaid, Tricare, etc),
  • Medicare Prescription Drug Program (Part D Program) or if you are currently in the coverage gap,
  • insurance that is paying the entire cost of the prescription, or
  • an insurer or other third-party payor in Massachusetts.
• Fill your prescription for ACTOS or an ACTOS combination product.
• Please follow the instructions on the Rebate Offer to get your savings.

Note to health professionals: This is to remind health professionals to provide eligible patients on ACTOS or on an ACTOS combination product with the ACTOS Advantage^® Program offer. If you need more certificates, please contact your Takeda Sales Representative or call 1-877-825-3327.

ACTOS^® is a registered trademark of Takeda Pharmaceutical Company Limited and used under license by Takeda Pharmaceuticals North America, Inc.

©2008 Takeda Pharmaceuticals North America, Inc.

*Terms and Conditions:

• You must meet Eligibility Requirements.
• You agree to report your use of this coupon to any third party that reimburses you or pays for any part of the prescription price.
• You additionally agree that you will not submit the cost of any portion of the product dispensed pursuant to this coupon to a federal or state healthcare program for purposes of counting it toward your out of pocket expenses (such as TrOOP under Medicare Part D or Medicaid).
• The amount of this offer is not to exceed $50 or your co-pay amount, whichever is less.
• This coupon is not valid with any other program, discount, or incentive involving ACTOS.
• Offer is invalid for submissions postmarked later than eight weeks from the dispense date on the original receipt.
• This offer may be restricted, revoked, or amended without notice.
• Valid for a minimum 30-day supply in US retail pharmacies only. No reproductions.
• Limit one coupon per purchase.
• Void where prohibited by law.