Register now to join the VIAGRA Advantage Program
Your Name
Last Name
email
Phone Number
Patient Date of Birth
Street Address
ZIP Code
City
State
Are you covered by Medicare, Medicaid, or any other government insurance? (FEHB is not included)
Yes
No
Do you currently have a prescription for VIAGRA?
Yes
No
Are you currently taking VIAGRA?
Yes
No
Yes, I agree to the terms and conditions of the VIAGRA Support Program. I hereby consent to receive text messages at the mobile number provided above.
I understand this consent is not a condition of purchase or use of VIAGRA or any product or service. I understand that I may revoke this consent at any time. View SMS Terms & Conditions
By completing this form and enrolling, you certify that you are 18+ years of age and give permission to use your personal information to receive product and disease-state information from Pfizer Pharmaceuticals U.S.A., Inc., its affiliates, service providers, and co-promotion partners and have your personal and health-related information that cannot identify you used for scientific and market research. You may revoke your permission at any time by contacting the company. A withdrawal does not have a retroactive effect. To learn how Pfizer will use and protect your personal information please review our Privacy Notice.
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VIAGRA Instant Savings Card Eligibility Rules
Eligibility Requirements: This offer cannot be used if you are a beneficiary of, or any part of your prescription is covered by: (1) any federal, state, or government-funded healthcare program (for example, Medicare, Medicaid, TRICARE), including a state pharmaceutical assistance program (the Federal Employees Health Benefits (FEHB) Program is not a government-funded healthcare program for purposes of this offer), (2) the Medicare Prescription Drug Program (Part D), or if you are currently in the coverage gap, or (3) insurance that is paying the entire cost of the prescription.
Terms & Conditions: You must meet Eligibility Requirements. You agree to report your use of this offer to any Third Party that reimburses you or pays for any part of the prescription price. Use of this offer is confirmation that you are permitted, under the terms and conditions of the health benefit plan(s) covering your prescriptions, to take advantage of co-pay coverage programs. You additionally agree that you will not submit the cost of any portion of the product dispensed pursuant to this offer to a federal or state healthcare program for purposes of counting it toward your out-of-pocket expenses. For commercially insured patients, this savings card covers out-of-pocket expenses greater than $20, up to a maximum benefit of $55 for a 30-day prescription or $165 for a 90-day prescription. For uninsured patients, the amount of this offer is not to exceed $55 for a 30-day prescription or $165 for a 90-day prescription. This coupon is not valid with any other program, discount, or incentive involving VIAGRA. This offer may be rescinded, revoked, or amended without notice. No reproductions. This offer is void where prohibited by law, taxed, or restricted. Limit one offer per purchase. Cash value of [1/100 of 1ยข.] For questions about this offer, call the Customer Service Center at 1-866-279-5598.
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