ATTENTION STUDENTS: 

Patient Eligibility Criteria for Gardasil Rebate Program

Merck & Co., manufacturers of Gardasil, the HPV vaccine, is offering a rebate for eligible vaccine recipients.

There are VERY SPECIFIC rules in order for you to be eligible to receive the Gardasil Patient Rebate from Merck & Co. We have outlined the most important rules below, but the full eligibility criteria can be read on Merck’s website:  (http://www.gardasil.com/rebate/terms.html) and is also detailed on the patient application which is available at Student health.

Please read through this entire summary as your application will be rejected if it is not complete or if you are determined to be ineligible. If you have questions, please speak to your provider for further information.

            In order to qualify for this rebate:

·         You must be female (as of January 1st, 2010 male recipients of Gardasil can receive rebate).

·         Women: you must have the dose of GARDASIL administered between April 1st, 2009, and December 31st, 2010.

       Men:  you must have the dose of GARDASIL administered between January 1st, 2010, and December 31st, 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 out-of-pocket cost for GARDASIL, neither you nor the person responsible for 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 form as described below. No other purchase is necessary.

·         Must submit a rebate form signed by healthcare provider (Nurse Practitioner or Doctor) along with a copy of Explanation of Benefits (EOB) form with EACH dose.

Rebate Terms

·         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 form must be provided and certifications must be signed. 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 form.

·         Rebate request submission must include:

·         This original rebate form. The form must be filled out completely and may not be modified in any manner. The form must contain original signatures.

·         A copy of the 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 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.

·         Merck & Co., Inc., reserves the right to rescind, cancel, or amend this offer at any time without notice.