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STEP 1

CHECK YOUR SAVINGS CARD ELIGIBILITY

Do you live in the United States, including Puerto Rico?
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Are you enrolled in Medicare, Medicaid, or another federal-, state-, or government-funded healthcare program?
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Do you certify that you understand and agree to comply with the Terms, Conditions, and Eligibility Criteria listed at the bottom of this page?
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error icon Based on the information you provided, you are not eligible to participate in this program.

Sorry, you are not eligible for the My Tears, My Rewards® Savings Card. Patients whose prescriptions are covered by Medicare, Medicaid, or a similar federal or state prescription drug program are not eligible for savings programs. Please see Terms, Conditions and Eligiblity for details.

DISCOVER SUPPORT AND SAVINGS

Sign up for the My Tears, My Support® program in order to receive information about Restasis® and other Allergan and AbbVie products and services.

STEP 2

ENTER YOUR CONTACT INFORMATION

*Required information

STEP 2

ENTER YOUR CONTACT INFORMATION

*Required information

MY TEARS, MY REWARDS® SAVINGS CARD DELIVERY OPTIONS


CONTACT US

For answers to questions about RESTASIS® and the My Tears, My Rewards® Program, call the toll-free customer service support line 1-844-4MY-TEARS (1-844-469-8327).

For answers to questions about RESTASIS® and the My Tears, My Rewards® Program, call the toll-free customer service support line 1-844-4MY-TEARS (1-844-469-8327).

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 RESTASIS MultiDose® bottles 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, TRI CARE, 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 My Tears, My Rewards® Savings Program. This offer is not valid for cash-paying patients. 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 prescription fills 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 (30-day supply) prescription fills of RESTASIS MultiDose® OR each of up to four (4) three-bottle (90-day supply) prescription fills of RESTASIS MultiDose®. 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, 2022. 5. Patients and healthcare providers may not seek reimbursement for value received from the My Tears, My Rewards® Savings Program from any third-party payers. 6. Allergan, 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, 2022. 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.

For 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 programs for this prescription. Submit the claim to the primary Third-party Payer first, then submit the balance due to Change Healthcare using BIN #004682 as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code (e.g., 8). If you receive a rejection due to PA, step-edit, or NDC block, submit Other Coverage Code of 03 (Secondary Claim). The patient's out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from Change Healthcare. For any questions regarding Change Healthcare online processing, call 1-866-371-9066.

Program managed by ConnectiveRx on behalf of Allergan, an AbbVie company

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