my tears, my rewards® savings program terms, conditions and eligibility criteria:
1. This offer is valid only for patients who have commercial insurance coverage and a valid prescription for an approved use of restasis® (cyclosporine ophthalmic emulsion) 0.05% single dose vials or multidose restasis ® bottles at the time the pharmacist fills the prescription and gives it to the patient. 2. This offer is not valid for use by patients enrolled in any federal, state, or government-funded health care programs (for example, medicare, medicare advantage, medigap, medicaid, tri care, department of defense, or foreign affairs programs). of veterans); private indemnity insurance plans or hmo’s that reimburse patients for the full cost of their prescription drugs; or where prohibited by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any federal, state, or government-funded health care program, the patient will no longer be eligible to participate in the My Tears, My Rewards® savings program. . This offer is not valid for patients paying cash. 3. Depending on insurance coverage, eligible patients may pay as little as $0 for each of up to twelve (12) 30-day prescription fills of restasis® single-use vials or each of up to four (4) 90-day refills of restasis® single-use vials. or, depending on insurance coverage, eligible patients may pay as little as $0 for each of up to twelve (12) one-bottle prescription fills (30-day supply) of restasis multidose® or each of up to four (4) three-bottle prescription fills (90-day supply) of restasis multidose®. see pharmacist for copay discount. maximum savings limits apply; patient out-of-pocket costs will vary. 4. offer applies only to prescriptions filled before the program period expires on December 31, 2022. 5. patients and healthcare providers cannot request reimbursement of the value received from the savings program my tears, my rewards® from any third party payers. 6. allergan, an abbvie company, reserves the right to terminate, revoke, or modify this offer without notice. 7. Offer valid only in the United States, including Puerto Rico and Guam, at participating retail pharmacies. patients residing in certain states may not be eligible to participate in this program. 8. void if prohibited by law, taxed or restricted. 9. This offer is not transferable. The law prohibits the sale, purchase, trade or counterfeiting of this offer. 10. This offer has no cash value and may not be used in conjunction with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. 11. This offer is not health insurance. 12. Offer expires December 31, 2022. 13. By redeeming this offer, patient represents that they meet the above eligibility criteria and understand and agree to abide by the terms and conditions of this offer.
If you have questions about this program, please call 1-844-4my-tears (1-844-469-8327).
Pharmacist instructions for a patient with an eligible third-party payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state or other government program for this prescription. submit claim to third party primary payer first, then submit balance due to change of care using container #004682 as secondary payer cob with patient responsibility amount and one other valid coverage code (eg, 8). If you receive a denial due to pa, step-edit, or ndc block, please submit another coverage code of 03 (secondary claim). the patient’s out-of-pocket expense will be reduced up to the maximum savings limit of the program. reimbursement will be received from change of medical care. If you have any questions about online care change processing, please call 1-866-371-9066.
program administered by connectiverx on behalf of allergan, an abbvie company