Desonate Tolerability Pledge

We're so confident that Desonate™ is a well-tolerated topical medication for mild to moderate atopic dermatitis, we'll back our claim with this pledge: if your doctor certifies that you have to stop using Desonate™ due to application site irritation (burning or stinging), we'll refund your out-of-pocket costs (costs that are not reimbursed by insurance).*

To obtain your Desonate Tolerability Pledge Refund, just follow these steps:

1. Print out this form.
2. Have your physician sign and date the form and provide his/her physician license number, certifying that you had to stop using Desonate due to lack of tolerability.
3. Completely fill out the rest of the form, including your signature and contact information.
4. Send the filled out form, along with your original receipt for one tube of Desonate, showing the drug name and your out-of-pocket costs for Desonate as proof of purchase, to the address below, no later than 90 days from the purchase date on your receipt. No photocopies will be accepted. Please retain a copy for your records.
   
   Desonate Tolerability Pledge
   c/o SkinMedica, Inc. Attn: Barbara Prall
   5909 Sea Lion Place, Suite H
   Carlsbad, CA 92010
   
   
5. You will receive a full refund of your out-of-pocket prescription cost for Desonate. Please allow 6-8 weeks for delivery. If you have questions, please call (800) 680-5212.

*Terms and conditions: The Desonate™ Tolerability Pledge is a limited warranty. Patients will receive reimbursement of their out-of-pocket drug costs for one tube of Desonate from SkinMedica, Inc. if they had to stop using Desonate due to application site irritation (stinging or burning). Patients must produce a copy of the original pharmacy receipt for their one tube of Desonate in order for the Pledge to be applicable. Additionally, the physician must sign and date the printable form from this website certifying that after the patient used Desonate as directed, they had to stop using the product because they suffered from irritation the healthcare professional believes was due to the product.

NOTE: Not valid for patients reimbursed by federal healthcare programs including Medicare, Medicaid, CHAMPUS, the Department of Veterans Affairs, state maternal and child health block grant programs under 42 U.S.C. Section 701et seq, state social services block grant programs under 42 U.S.C. section 1397 et. seq. or any other similar federal or state healthcare program; of for patients in MA, MI, MN, and OH. Offer void where prohibited by law, taxed or restricted. No group or organization request will be honored. SkinMedica, Inc. reserves the right to rescind, revoke or amend this offer at any time without notice. This warranty gives you specific legal rights, and you may also have other rights which vary from state to state. Limit one reimbursement per household. This form must be completed in full; incomplete forms will not be returned or processed. For more information on Desonate or the Desonate Tolerability Pledge, call (800) 680-5212.