Patient Terms and Conditions:

Please visit MyEyeSavings.com to acquire and activate your Eyevance Copay Savings Program Card and present it along with a valid prescription to the pharmacy to participate in this savings program. If you have questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the Eyevance Copay Savings Program at 1.866.747.0976 (9 a.m. – 6 p.m. ET, Monday – Friday). For patients whose prescriptions are covered by commercial insurance, use of this card may reduce your copayment responsibility to as little as $49. For patients whose prescriptions are not covered by either commercial or Medicare Part D and Medicare Advantage insurance, use of this card may reduce your cost for prescriptions to as little as $59. This program is subject to overall maximum support amounts. This coupon is not valid for prescriptions paid for in part or full by Medicaid, Tricare, DOD, VA, or any state or federally funded program (excluding Medicare). Patients who have prescription drug coverage under Medicare Part D or Medicare Advantage may take advantage of this offer, provided that they acknowledge that by doing so they will not seek any prescription coverage or reimbursement from their insurer for the cost of prescriptions or report any amounts paid for prescriptions as part of their “true out-of-pocket expenses” under Medicare Part D or Medicare Advantage prescription drug plan. When you use this card, you are certifying that you understand the program rules, regulations, and terms and conditions, and that you have responded truthfully to questions when activating this card.

Pharmacist Instructions:

• For commercially insured patients: Submit the claim to the primary Third Party Payer first, then submit the balance due to Change Healthcare as a Secondary Payer COB with patient responsibility amount and a valid Other Coverage Code (OCC 3,8). The patient is responsible for the first $49.00 (patients with no product coverage will be responsible for the first $59) and reimbursement for the balance, up to the program maximum, will be received from Change Healthcare.
• For Cash and Medicare Part D insured patients opting out of their plan coverage and agreeing to the program terms: Submit this claim to Change Healthcare as Cash. A valid Other Coverage Code (OCC 0,1) is required. The patient is responsible for the !rst $59.00 and reimbursement for the balance, up to the program maximum, will be received from Change Healthcare.

For pharmacy processing questions, please call 1-800-422-5604.

Program Terms and Conditions:

The Eyevance Copay Savings Program card is not valid for use with any other prescription drug discount or cash cards for FLAREX^®, TOBRADEX^® ST, and/or ZERVIATE^®. Claims submitted utilizing the program are subject to audit or validation.

When you process this card, you are certifying that you have read, understood, and are in compliance with the terms and conditions pertaining to this program. You are further certifying that you have not submitted and will not submit a claim for reimbursement under Medicare Part D or similar federal or state programs including any state medical pharmaceutical assistance program for this prescription.

Eyevance reserves the right to rescind, revoke, or amend this offer at any time.