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Enter patient information
We need some information from the patient’s prescription
insurance card to complete the estimate
Based on currently available information,
’s estimated copay for
with [Payer Info/insurance name] is:
$50 for a 30-day supply*
*This is not a guarantee of coverage or payment for the medication as third-party payment for
prescription medication is affected by numerous factors.
Eligible commercially-insured patients may pay as little as $0
$30†
per 90-day prescription fill.
†Maximum savings limits apply; patient out-of-pocket expense will vary depending on insurance coverage. Offer valid for patients with commercial prescription insurance coverage and a valid prescription for LUMIGAN® 0.01%, COMBIGAN®, or ALPHAGAN® P 0.1%. Offer not valid for patients enrolled in Medicare, Medicaid, or any other federal, state, or government-funded healthcare program. See At Your Service Savings Program Terms, Conditions, and Eligibility Criteria at savewithays.com.
PATIENT DEDUCTIBLE
Amount Remaining: $500
Amount Accumulated: $1500
To receive the RESTASIS® At Your Service
copay savings card, have [PATIENT FIRST NAME]
text SAVE SAVINGS to 72428‡
‡AYS Alerts: Msg and data rates apply. Msg frequency depends on user. Reply HELP for help; reply STOP to cancel. Consent to texts not required to sign up for offer. View our Mobile Terms & Conditions and Privacy Policy.
It appears that DG has recently filled their prescription. We are not able to estimate their copay just yet, but please try again closer to their next refill.
[PATIENT FIRST NAME]’s estimated copay for
with [Payer Info/insurance name] is:
for a 30-day supply*
*This is not a guarantee of coverage or payment for the medication as third-party payment for prescription medication is affected by numerous factors. PATIENT DEDUCTIBLE Amount Remaining: $500 Amount Accumulated: $1500
It appears that D has recently filled their prescription. We are not able to estimate their copay just yet, but please try again closer to their next refill.
Make sure your patient receives the copay offer by enrolling for the RESTASIS® At Your Service Savings Card.
To start saving, have [PATIENT FIRST NAME] text SAVE SAVINGS to 72428*
†AYS Alerts: Msg and data rates apply. Msg frequency depends on user. Reply HELP for help; reply STOP to cancel. Consent to texts not required to sign up for offer. View our Mobile Terms & Conditions and Privacy Policy.
C may be covered,
but a Prior Authorization is required.
You will need to submit a Prior Authorization (PA) to your patient’s insurance for . We can help with your patient's PA through our partnership with PARx!
Commercially-insured patients may be eligible for the
RESTASIS® At Your Service Savings Card!
To start saving, have D text SAVE SAVINGS to 72428*
†AYS Alerts: Msg and data rates apply. Msg frequency depends on user. Reply HELP for help; reply STOP to cancel. Consent to texts not required to sign up for offer. View our Mobile Terms & Conditions and Privacy Policy.
E’s insurance does not cover
at this time, but it may be covered with a Formulary Exception if medically necessary.
We're sorry; coverage cannot be determined
with the information you provided.
Please contact your patient's insurance to
confirm eligibility.
To make sure you get the medication your
doctor prescribed, and the correct copay,
ask the pharmacist:
- Is this price the copay for the medication my doctor prescribed?
- Did you run my insurance and apply the savings program?
You can also check the bottle for the name and amount of
medication to make sure it is what your doctor prescribed.
Remember, your doctor prescribed this medication because a
substitute is not recommended.
Congratulations, !
You have completed enrollment for your At Your Service Savings Card.
You will receive a confirmation email shortly with your savings card details.
If you do not have access to a printer, please download the PDF to view and write down the following information.
- BIN 600426
- PCN 54
- GRP EC51034002
- ID
Allergan is here to help Most eligible commercially-insured patients pay as little as
$30 per prescription*
That's as little as $10 per month for a 90-day supply
or call 1-833-Dial-AYS (1-833-342-5297)
or text SAVINGS to (72428)†
Eyecare Professionals:
*AYS Savings Program Terms, Conditions, & Eligibility Criteria
1. This offer is valid only for patients who have commercial insurance coverage and a valid prescription for an approved use of LUMIGAN® (bimatoprost ophthalmic solution) 0.01%, COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5%, or ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1% at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. This offer is not valid for use by patients enrolled in any federal, state, or government-funded healthcare programs (e.g., Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs); private indemnity or HMO insurance plans that reimburse patients for the entire 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 healthcare program, patient will no longer be eligible to participate in the At Your Service Savings Program. This offer is not valid for cash-paying patients. 3. Depending on insurance coverage, eligible patients may pay as little as $30 per prescription for each of up to thirteen (13) 30-day prescription fills OR each of up to five (5) 90-day prescription fills. Check with pharmacist for copay discount. Maximum savings limits apply; patient out-of-pocket expense will vary. 4. Offer applies only to prescriptions filled before program period expires on December 31, 2023. 5. Patients and healthcare providers may not seek reimbursement for value received from the At Your Service Savings Program from any third-party payers. 6. Allergan, Inc., an Abbvie company, reserves the right to rescind, revoke, or amend this offer without notice. 7. Offer good only in the USA, 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 selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. 10. This offer has no cash value and may not be used in combination 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, 2023. 13. By redeeming this offer, patient represents they meet the eligibility criteria above and patient understands and agrees to comply with the terms and conditions of this offer.
Subject to all other terms and conditions, the maximum annual benefit that may be available solely for the patient's benefit under the copay assistance program is $170 per fill for a 30-day supply, or $400 per fill for a 90-day supply throughout the calendar year.
For questions about this program, please call 1-833-Dial-AYS (1-833-342-5297).
Program managed by ConnectiveRx on behalf of Allergan, Inc., an Abbvie company.
†AYS Alerts: Msg and data rates apply. Msg frequency depends on user. Reply HELP for help; reply STOP to cancel. Consent to texts not required to sign up for offer. View our Mobile Terms & Conditions and Privacy Policy.