RESTASIS® (Cyclosporine Ophthalmic Emulsion) 0.05% My Tears, My Rewards® is a counseling, savings, and support program offered to
eligible enrollees free of charge.
According to state and federal laws, patients covered by Medicare, Medicaid, or a similar federal or state healthcare program are not eligible for savings programs.
This program is offered only in the United States and Puerto Rico.
My Tears, My Rewards® Savings Card
To activate your My Tears, My Rewards® Savings Card, call 1-844-4MY-TEARS (1-844-469-8327). The call will take just a few minutes. You will need to provide a valid mailing and e-mail address so we can send you helpful treatment and program information, free samples, and other offers.
Go to your pharmacy and present your card along with your RESTASIS® prescription to your pharmacist. Ask your pharmacist for the dollar amount saved with your card after your prescription has been processed; then pay any difference between the amount owed and the amount saved.
If you use your savings card to fill your RESTASIS® prescription within 10 days of the date you call to activate your card, you may be eligible to receive an additional $10 savings off your first prescription.
My Tears, My Rewards® (90-Day) Program
For each 90-day RESTASIS® prescription you may be entitled to receive up to $90 off refills 1, 2, 3, and 4.
You may be entitled to an additional $10 in savings if you refill a 90-day prescription within 100 days of your prior 90-day prescription refill.
When using RESTASIS®, you will need to use two (2) vials (eye drop packages) each day. Only RESTASIS® prescriptions for a 90-day
supply of 180 vials total can be redeemed toward these savings. No other refill quantities will qualify.
My Tears, My Rewards® (30-Day) Program
For each 30-day RESTASIS® prescription you will receive up to $20 off every month, provided the prescription is filled within 40 days. You
will have no copay up to $85 off on refills 4, 8, and 12 if filled within 40 days.
You may be entitled to up to an additional $10 in savings if you refill a 30-day prescription within 40 days of your prior 30-day prescription
When using RESTASIS®, you will need to use two (2) vials (eye drop packages) each day. Only RESTASIS® prescriptions for a 30-day
supply of 60 vials total can be redeemed toward these savings. No other refill quantities will qualify.
RESTASIS® My Tears, My Rewards® Program for Mail-Order/Manual Claims
If your mail-order pharmacy or pharmacy does not accept the My Tears, My Rewards® Savings Card, here is what you can do:
- Download and complete a Manual Claim Form
- Print and complete the form, attach your receipt, and send both to the address on the form. In 3 to 6 weeks your check will arrive in the mail.
PSKW Attn: RESTASIS® Claims Processing Dept, PO BOX 7017, Bedminster, NJ 07921
You will be mailed a check for the applicable benefit amount. In 3 to 6 weeks your check will arrive in the mail.
My Tears, My Rewards® Savings Card Expiration and Reenrollment
Your My Tears, My Rewards® Savings Card expires on the date that occurs first between the following :
- One year from the date that you first use your card to pay for a prescription, OR
The last day of the expiration month and year on your savings card
– For example: if your card says 12/15, your card expires on December 31, 2015
– If this happens before you complete the program, please get a new card by calling 1-844-4MY-TEARS (1-844-469-8327)
After the card expires, you may be able to sign up again (depending on program rules). You will automatically be sent a new card and other
materials necessary to continue to benefit from the program if you:
- Actively participate in the program*
- Use your card per instructions provided
Allergan reserves the right to revise or discontinue this program at any time and without prior notice or recourse.
*Actively participating is defined as: using at least 3 times in the last 10 months for those with 30-day prescriptions and using at least twice in the last 10 months for those with 90-day prescriptions.