Physician information

Search physicians using the fields below:

PHYSICIAN’S FIRST NAME

PHYSICIAN’S LAST NAME

PHYSICIAN’S STATE

Search Physicians

Search by NPI

Patient information

Enter patient information

Does the patient have insurance?

Yes

Please select an option above.

FIRST NAME

LAST NAME

DATE OF BIRTH

ZIP CODE

Patient gender

Male Female

Please select an option above.

Is the patient listed above also the main policy holder
of the prescription insurance plan?

Yes No

Please select an option above.

By checking this box, I certify the following: (1) that the person named on this form is my patient; (2) that I have obtained his/her written consent to release the patient-identifiable information on this form to Allergan^®, including any affiliates, representatives, contractors, and/or agents of Allergan^® (collectively “Allergan^®”), for the purpose of conducting insurance verification and co-pay estimation; and (3) that I will retain a complete patient-executed copy of the patient’s consent to release their patient-identifiable information.

Great news!

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.

Reduce your patient's copay to as low as
$0 $15 for a 30- or 90-day^† supply with the
RESTASIS^® At Your Service Savings Card! That's as little as $5 per month for a 90-day supply.^† ^†Terms and conditions apply. Please note that not all insurance carriers cover a 90-day supply. PATIENT DEDUCTIBLE Amount Remaining: $500 Amount Accumulated: $1500

To ensure the
RESTASIS^® At Your Service copay,
have [PATIENT FIRST NAME] text SAVE SAVINGS to 72428

Good news! Your patient is covered.

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.

Great news!

[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

Good news! Your patient is covered.

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

Your patient may be covered.

C may be covered,
but a Prior Authorization is required.

You will need to submit a Prior Authorization 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