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Enter patient information

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

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 DEDUCTIBLEAmount Remaining: $500Amount 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.

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.

[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 DEDUCTIBLEAmount Remaining: $500Amount Accumulated: $1500

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.

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.}

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

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

Please contact your patient's insurance to
confirm eligibility.

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

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.

Congratulations, !

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

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

If you do not have access to a printer, please download the PDF to view and write down the following information.