Physician information

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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

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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, Inc., an Abbvie company, including any affiliates, representatives, contractors, and/or agents of Allergan^® (collectively “Allergan^®”), for the purpose of conducting insurance verification and copay 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.

Eligible commercially-insured patients may pay as little as $0 $15^†
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.

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* ^†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.

Your patient may be covered.

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.

GET PA SUPPORT WITH PARx

Your patient is not covered.

E’s insurance does not cover
at this time, but it may be covered with a Formulary Exception if medically necessary.

GET FORMULARY SUPPORT WITH PARx

Unable to determine coverage.

We're sorry; coverage cannot be determined
with the information you provided.

Please contact your patient's insurance to
confirm eligibility.

ESTIMATE FOR SAME PATIENT ESTIMATE FOR NEW PATIENT

DONE

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.

Does the patient have insurance?

Patient gender

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

To make sure you get the medication your doctor prescribed, and the correct copay, ask the pharmacist:

Congratulations, !

You have completed enrollment for your At Your Service Savings Card.

Contact Us

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

To make sure you get the medication your
doctor prescribed, and the correct copay,
ask the pharmacist: