Voucher Topamax

TOPAMAX can help
change the way

you manage
your migraines.
www.TOPAMAX.com
I f you’re thinking about migraines even when

you’re not having one, it may be time for a change.
These questions will help your doctor understand what your migraines are like and
how they affect your daily life. Use them to guide your discussion about migraines
with your doctor so he or she can recommend the right treatment for you.
• Do you take over-the-counter or prescription medications more than twice a week for migraine pain?
• Are these medications no longer helpful for you?
• Do you have 2 or more migraine attacks a month that impact your daily activities for 3 or more days?
• Do migraines impact your work, family, or social life? Please provide specific examples.
• In between migraine attacks, do you think about when the next one may strike and what the impact will be?
Please provide specific examples.
• Do you make contingency plans or take other actions in anticipation of a possible migraine attack?
Please provide specific examples.
Free trial offer for up to 42 (25 mg)
TOPAMAX can help stop migraines before they start

so you can get fewer of them to think about.
Is TOPAMAX right for me? Just follow these 3 easy steps:
To the Patient: To the Pharmacist:

1. Talk to your doctor to find out if TOPAMAX is right • This voucher must be accompanied by a valid prescription
for you. TOPAMAX is available by prescription only. for up to 42 TOPAMAX 25 mg tablets.
2. If your doctor prescribes TOPAMAX, you can get up to • Please dispense up to 42 TOPAMAX 25 mg tablets at no
42 (25 mg) tablets free from your pharmacist with this offer. charge to the patient.
3. Present your written prescription for up to 42 TOPAMAX • Medication errors have occurred involving TOPAMAX.
25 mg tablets and this voucher to your pharmacist to receive Double-check that the prescription you are filling is for
your free trial of TOPAMAX. In order to process your TOPAMAX.
voucher, please read and sign below. • Voucher valid only with patient signature.
By signing and dating below, you understand and consent • Claim must be submitted within 14 days of prescription fill.
that your personal information will be used and disclosed to • Limited to 1 free trial voucher redemption per person for
vendors working on behalf of Ortho-McNeil Neurologics, the duration of the program.
Inc., solely to administer reimbursement to your pharmacy
and/or verify compliance with program rules and restrictions.
• Also refer to eligibility restrictions.
Pharmacy Processing:
• Submit claim to McKesson Specialty using the information
Patient’s Signature Date listed below.
Conditions of Use:
• This voucher must be attached to the original prescription
and retained by pharmacy for audit purposes for the period
• Limited to 1 TOPAMAX free trial voucher redemption of 3 years or the usual period for which your pharmacy
per person. records are kept, whichever is longer.
• Ortho-McNeil Neurologics, Inc., reserves the right to rescind, • For additional information or questions regarding pharmacy
revoke, or amend this offer at any time without notice. processing or rules and regulations governing this program,
• This voucher is not valid through mail-order pharmacies. please call the Help Desk at 1-800-750-9835.
• Subject to eligibility restrictions listed on this voucher. • I certify that: i) I have dispensed the TOPAMAX product to an
eligible patient, ii) I have not submitted and will not submit a
To the Physician:
claim for reimbursement to the patient or any third-party
• In order to use this voucher, your patient will require a valid payer, and iii) my participation in this program complies with
signed prescription for up to 42 TOPAMAX 25 mg tablets.
all applicable laws and contractual or other obligations I have
• Please provide your patient with a separate prescription if as a pharmacy provider.
you wish them to continue beyond this trial.
• Also refer to eligibility restrictions.
Recommended Initial Dosing: Pharmacist’s Signature Date
TOPAMAX should be taken at the dose recommended by the Eligibility Restrictions:
healthcare professional to achieve the best results and to help Claims for any product dispensed pursuant to terms of voucher
minimize side effects. shall not be submitted to any public (eg, Medicaid) or private
Morning Dose Evening Dose (eg, insurance company) payer for reimbursement. The selling,
purchasing, trading or counterfeiting of this voucher is prohibited
Week 1 none 25 mg by federal law, and such activities may result in imprisonment for
Week 2 25 mg 25 mg not more than 10 years or fines not more than $250,000, or both.
Week 3 25 mg 50 mg No purchase or co-pay required. No substitutions permitted. Not
(2-25 mg tablets) valid through mail-order pharmacies. Void where prohibited by
law. Void outside the USA. Ortho-McNeil Neurologics, Inc.,
Week 4 & beyond 50 mg 50 mg reserves the right to rescind, revoke, or amend this offer at any
time without notice. NO PHOTOCOPIES ACCEPTED.
Utilize the Following Codes for Processing:

02M984 BIN# 610500 Group# H1690100 ID# DEV087455 Expires June 30, 2008

Voucher Topamax

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TOPAMAX can help

change the way

I f you’re thinking about migraines even when

TOPAMAX can help stop migraines before they start

To the Patient: To the Pharmacist:

Utilize the Following Codes for Processing:

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