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STEP 1/2
PATIENT COPAY ESTIMATOR
Physician information
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STEP 2/2
Patient information
Enter patient information
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We need some information from the patient’s prescription insurance card to complete the estimate
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.
Great news!
Based on currently available information, ’s estimated copay for LUMIGAN® (bimatoprost ophthalmic solution) 0.01% COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5% ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1% RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% RESTASIS MultiDose® (cyclosporine ophthalmic emulsion) 0.05% 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.
Eligible commercially-insured patients may pay as little as $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: N/A
Amount Accumulated: N/A
To receive the At Your Service RESTASIS copay savings card, have 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.
[PATIENT FIRST NAME]’s estimated copay for LUMIGAN® (bimatoprost ophthalmic solution) 0.01% COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5% ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1% RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% RESTASIS MultiDose® (cyclosporine ophthalmic emulsion) 0.05% with [Payer Info/insurance name] is:
*This is not a guarantee of coverage or payment for the medication as third-party payment for prescription medication is affected by numerous factors.
Your Patient may be covered
may be covered, but a Prior Authorization is required.
You will need to submit a Prior Authorization (PA) to your patient’s insurance for LUMIGAN® (bimatoprost ophthalmic solution) 0.01%COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5%ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1%RESTASIS® (cyclosporine ophthalmic emulsion) 0.05%RESTASIS MultiDose® (cyclosporine ophthalmic emulsion) 0.05%. We can help with your patient's PA through our partnership with PARx!
Commercially-insured patients may be eligible for the At Your Service Savings Card!
To start saving, have text SAVE SAVINGS to 72428*
Good news! Your Patient is covered.
It appears that 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 At Your Service Savings Card.
Your Patient is not covered
’s insurance does not cover LUMIGAN® (bimatoprost ophthalmic solution) 0.01% COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5% ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1% RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% RESTASIS MultiDose® (cyclosporine ophthalmic emulsion) 0.05% at this time, but it may be covered with a Formulary Exception if medically necessary.
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.
You will need to submit a Prior Authorization (PA) to your patient’s insurance for LUMIGAN® (bimatoprost ophthalmic solution) 0.01% COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5% ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1% RESTASIS® (cyclosporine ophthalmic emulsion) 0.05% RESTASIS MultiDose® (cyclosporine ophthalmic emulsion) 0.05%. We can help with your patient's PA through our partnership with PARx!
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