* Are you, or the patient currently enrolled in
Medicare, Medicare Part D, Medicaid, TriCare, Veterans Administration,
State Pharmaceutical Assistance programs, or other Federal or State programs?
This program is not valid for prescriptions reimbursed under
Medicare, Medicaid, VA, DoD, (TRICARE), Indian Health
Services, or other similar federal or state program.
* Please indicate the state in which the patient resides