Patient Eligibility Criteria

In order to qualify for this rebate:

• If you are female, you must have the dose of GARDASIL administered between April 1, 2009, and December 31, 2010. If you are male, you must have the dose administered between January 1, 2010, and December 31, 2010.
• You must be between the ages of 19 and 26 when the dose of GARDASIL is administered.
• You must have private health insurance at the time the dose of GARDASIL is administered. The rebate is not valid for uninsured patients or patients covered under a government-funded program such as Medicaid, Medicare, Veterans Benefits, TRICARE, or any other state or federal program.
• You must be a resident of the United States and the dose of GARDASIL must be administered in the United States.
• You must not be a resident of Colorado or Massachusetts. NOTE: If a person other than you is responsible for the out-of-pocket cost for GARDASIL, neither you nor the person responsible for the out-of-pocket cost may be residents of Colorado or Massachusetts.
• You or the person responsible for the out-of-pocket cost must have paid or must be obligated to pay in excess of $30 for the dose of GARDASIL for which a rebate is sought. You must submit the required documentation with this rebate request form as described below.
• No other purchase is necessary.

Rebate Terms

• For females, rebate is valid for doses of GARDASIL administered between April 1, 2009, and December 31, 2010. Doses administered before April 1, 2009, or after December 31, 2010, will not qualify for a rebate.
• For males, rebate is valid for doses of GARDASIL administered between January 1, 2010, and December 31, 2010. Doses administered before January 1, 2010, or after December 31, 2010, will not qualify for a rebate.
• Rebate is valid only if the patient has private health insurance and the patient or the person responsible for the out-of-pocket cost for the dose of GARDASIL that was administered has paid or is obligated to pay in excess of $30. Rebate is limited to the amount the patient's private health insurance company indicates on the patient's Explanation of Benefits (EOB) that the patient or the person responsible for the out-of-pocket cost is obligated to pay for the dose minus $30, up to a maximum of $130. The maximum rebate for each dose administered is $130, regardless of the amount the patient or the person responsible for the out-of-pocket cost for the dose actually paid or is obligated to pay.
• Rebate is valid for the out-of-pocket cost for the dose of GARDASIL only. Rebate is not valid for any other products or other out-of-pocket costs (for example, office visit charges, office visit co-payments, or vaccine administration charges) even if such costs are associated with the administration of the dose of GARDASIL.
• Only the patient or the person responsible for the out-of-pocket cost for the dose of GARDASIL may request the rebate. The patient's doctor or health care professional may not request the rebate on behalf of the patient and may not receive the rebate directly from Merck. The patient or the person responsible for the out-of-pocket cost remains obligated to pay the doctor or health care professional for the dose of GARDASIL.
• Patient is limited to three (3) rebate request submissions (one for each dose of GARDASIL provided the patient meets eligibility criteria and Terms and Conditions for each dose).
• This rebate request form must be postmarked within 90 days of the date of administration of the dose of GARDASIL for which a rebate is sought. If the Terms and Conditions are met, the rebate will be paid to the person responsible for the out-of-pocket cost.
• All information requested on the rebate request form must be provided and certifications must be signed. Rebate request forms that are not filled out completely or are modified will not be eligible for a rebate. The patient or the person responsible for the out-of-pocket cost for the dose of GARDASIL must ensure that the doctor or health care professional completes the Health Care Professional Certification portion of the rebate request form.
• Rebate request submission must include:
• This original rebate request form. The rebate request form must be filled out completely and may not be modified in any manner. The rebate request form must contain original signatures.
• A copy of the patient's EOB from the private health insurance company reflecting the out-of-pocket cost for the dose of GARDASIL for which the patient or the person responsible for the out-of-pocket cost is requesting a rebate.
• Rebate is nontransferable. No substitutions are permitted.
• Rebate request form is void if reproduced or if modified in any manner.
• Rebate is void where prohibited by law, taxed, or restricted.
• It is illegal for any person to sell, purchase, trade, or counterfeit this rebate request form.
• Rebate cannot be combined with any other offer, including any rebate, coupon, savings card, or discount.
• Rebate is not health insurance or a substitute for health insurance.
• This rebate request form is the property of Merck and must be turned in on request.
• Merck reserves the right to rescind, cancel, or amend this offer at any time without notice.