support that simplifies access 

TERMS, CONDITIONS, AND ELIGIBILITY CRITERIA

1. This card is not valid for prescriptions submitted for reimbursement to Medicare, Medicaid, Medigap, VA, DOD, or TriCare, or where prohibited by law; to other federal or state programs (including any state pharmaceutical assistance programs); or to private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this card if Amerithroid is covered under their Medicare prescription drug plan or if they are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.
   
   

2. This card is good for use only with an Amerithroid prescription at the time the prescription is filled by the pharmacist and dispensed to the patient.
   
   

3. This offer is good for 18 uses per patient, per calendar year, or until the program expires, whichever comes first.
   
   

4. Maximum reimbursement limits apply; patient out-of-pocket expenses may vary.
   
   

5. Oliva reserves the right to rescind, revoke, or amend this offer without notice.
   
   

6. Offer good only in the US, except California and Massachusetts, at participating retail pharmacies.
   
   

7. Void if prohibited by law, taxed, or restricted.
   
   

8. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law.

By downloading the savings card, I certify that I am not covered by:

• Any federal or state healthcare program, such as Medicare, Medicaid, etc., including state medical or pharmaceutical assistance programs;

• The Medicare Prescription Drug Program (Part D), or in the coverage gap; or

• Insurance that is paying the entire cost of the prescription

I agree to this certification and have read and accepted the Program Terms, Conditions, and Eligibility Criteria.

I certify that I am 18 years of age or older and completing this for myself or a dependent.