Please follow these 4 steps if you are eligible for a refund:

  • STEP 1: Save your original pharmacy receipt(s). Your receipt(s) must show: BELSOMRA was purchased, the date(s) the prescription was purchased, and the price you paid for BELSOMRA (your out-of-pocket cost). At least 7 days must have elapsed between the date your claim is postmarked and the date on your receipt.
  • STEP 2: Download, Print and Complete the Refund Request Form. Click here to download the Request Form
    The form must include your information and original signature. No signature stamps will be accepted. Also attach a copy of the front and back of your private insurance card.
  • STEP 3: Sign and clearly print your name and mailing address.
  • STEP 4: Mail your original pharmacy receipt(s), a copy of your insurance card, and completed Refund Request Form to:
    Refund Request • PO Box 29 • Horsham, PA 19044-0029.
    This Refund Request Form must be postmarked within 90 days of the date when the prescription was purchased, as indicated on your pharmacy receipt.

Terms and Conditions for the BELSOMRA® (suvorexant) Pledge Program

  • You must be 18 years of age or older.
  • You must purchase your qualifying prescription of BELSOMRA® (suvorexant) between September 1, 2018, and December 31, 2019. Refund is valid only for 1 qualifying prescription of BELSOMRA (up to 30 tablets). Prescriptions for BELSOMRA purchased before September 1, 2018, or after December 31, 2019, will not qualify for a refund.
  • You must have a co-payment or if you are privately insured without coverage for the product, make a full cash payment, for the prescription.
  • Patient must have private insurance. Not valid for uninsured patients or patients covered under Medicaid (including Medicaid patients enrolled in a qualified health plan purchased through a health insurance exchange [marketplace] established by a state government or the federal government), Medicare, a Medicare Part D, or Medicare Advantage plan (regardless of whether a specific prescription is covered), TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan (“Healthcare Reform”), or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program (collectively, “Government Programs”).
  • Absent a change in Massachusetts law, effective July 1, 2019, residents of Massachusetts will no longer be eligible for a refund.
  • You must be a resident of the United States or the Commonwealth of Puerto Rico. Product must be purchased at participating eligible retail or mail-order pharmacies in the United States or the Commonwealth of Puerto Rico. Product must originate in the United States or the Commonwealth of Puerto Rico.
  • No other purchase is necessary.
  • The maximum amount of any refund will be equal to the out-of-pocket cost paid for 1 qualifying prescription of BELSOMRA (up to 30 tablets) not to exceed $400.
  • Refund is not valid for any other products, other out-of-pocket costs listed on your submitted pharmacy receipt, or your prescriber visit co-pay.
  • Only the patient may request the refund. The patient’s prescriber or healthcare professional may not request the refund on behalf of the patient and may not receive the refund.
  • Patient is limited to one (1) refund request submission, provided the patient meets eligibility requirements and Terms and Conditions.
  • This Refund Request Form must be postmarked within 90 days of the date of purchase, as indicated on your pharmacy receipt. Refund Request Forms postmarked after 90 days of the date of purchase will not be honored.
  • If the Terms and Conditions are met, the refund will be paid to the patient submitting the refund request.
  • All information requested on the Refund Request Form must be provided, and the certification must be signed. Forms that are not filled out completely or are modified will not be eligible for a refund.
  • You must submit the required documentation with this Refund Request Form. Refund request submission must include:
    • ­This original Refund Request Form. This form must be filled out completely and may not be modified in any manner. This form must contain an original signature. No signature stamps will be accepted.
    • The original pharmacy receipt indicating that the product you purchased was BELSOMRA, the date the prescription was purchased, and the price you paid out-of-pocket for BELSOMRA. At least 7 days must have elapsed between the date your claim is postmarked and the date on your receipt.
    • ­A copy of the front and back of your private insurance card must be attached.
  • This refund is not transferable. No substitutions are permitted.
  • This Refund Request Form is void if reproduced and void where prohibited by law, taxed, or restricted.
  • It is illegal to sell, purchase, trade, or counterfeit this Refund Request Form.
  • Patient, pharmacist, and prescriber agree not to seek reimbursement for all or any part of the benefit received by the patient through this offer. Patient is responsible for reporting receipt of refund to any insurer, health plan, or other third party who pays for or reimburses any part of the prescription for which a refund has been received as may be required.
  • If a coupon or savings card was used for the prescription submitted for refund, the pharmacy receipt must clearly reflect the actual cost paid by the patient after the coupon or savings card was applied.
  • This refund is not insurance or a substitute for insurance.
  • This Refund Request Form is the property of Merck and must be turned in on request.
  • Merck reserves the right to rescind, revoke, or amend this offer at any time without notice.
  • Expiration date: December 31, 2019.