• Important Safety Information
  • Important Safety Information
  • Important Safety Information
SaveWithAYSLogo
  • Important Safety Information
    • LUMIGAN® 0.01%
    • COMBIGAN®
    • ALPHAGAN® P 0.1%
  • LumiganLogo
  • alphagan-logo
  • CombiganLogo
STEP 1/2
PATIENT COPAY ESTIMATOR
Physician information

Search physicians using the fields below:

Please enter physician's first name.
Please enter physician's last name.
Please enter physician's state.
Search Physicians
Search by NPI
Select physician:
RESULTS: 
Please select an answer.
Physician information

Search physicians using the field below:

Please enter physician's NPI.
Search Physicians
Search by Name and State
Select physician:
RESULTS: 
Please select an answer.
Patient information

Enter patient information

Does the patient have insurance?

Please select an option above.
Please enter first name.
Please enter last name.
Please enter date of birth.
Please enter ZIP code.

Patient gender

Please select an option above.
Please select a product.

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

Please select an option above.
Patient information

We need some information from the patient’s prescription
insurance card to complete the estimate

Please enter RX BIN.

If your patient's prescription insurance card has an RX PCN, please enter it. You can leave this blank only if you do not see one on the card.

Enter RX PCN
We need some information from the patient’s prescription insurance card to complete the calculation
Please enter RX group.
Please enter member ID.
Great news! PRINT

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.

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! PRINT

[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.

STEP 1/2 STEP 2/2

Congratulations, !

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

You will receive a confirmation email shortly with your savings card details.

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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

Contact Us

Allergan At Your Service Customer Service
1-833-Dial-AYS (1-833-342-5297)

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