BOTOX® Savings Program Terms and Conditions
Program Terms, Conditions, and Eligibility Criteria:
1. Offer good only with a valid prescription for BOTOX® (onabotulinumtoxinA).
2. Based on insurance coverage, reimbursement may be up to
$1500 per treatment with a maximum savings limit of $4000 per year; patient out-of-pocket expense may vary. 3. Offer not valid for (a) patients enrolled in Medicare, Medicaid, TRICARE or any other government-reimbursed healthcare program (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse for the entire cost of prescription drugs; (b) patients who are Medicare-eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees; (c) cash-paying patients. 4. Offer valid for up to 4 treatments over a 12-month period; offer is valid for a 5th treatment for Chronic Migraine. 5. Offer valid only for BOTOX® and BOTOX® treatment-related costs not covered by insurance. For residents of Massachusetts, Michigan, Minnesota and Rhode Island, offer applies only to the cost of BOTOX® and not to any related medical service(s). 6. Claims must be submitted within 180 days of treatment date and must include a copy of (a) an Explanation of Benefits (EOB) for the BOTOX® treatment, (b) a Specialty Pharmacy (SP) receipt for BOTOX®, or (c) other writing showing payment of out-of-pocket BOTOX® and treatment-related out-of-pocket costs. 7. A BOTOX® Savings Program check will be provided upon approval of a claim and may be sent either directly to you or to your authorized healthcare provider who provided treatment. For payment to be made to your healthcare provider, an authorized assignment of benefit also must be included with the Claim. Assigning your BOTOX® Savings Program benefit to your healthcare provider is not required to participate in the program. 8. Allergan® reserves the right to rescind, revoke, or amend this offer without notice. 9. Offer good only in the USA, including Puerto Rico, at participating retail locations. 10. Void where prohibited by law, taxed, or restricted. 11. Offer does not constitute health insurance. 12. By participating in the BOTOX® Savings Program, you acknowledge and agree to the terms and conditions of this program.
For questions about this program, please call 1-800-44-BOTOX.