Patients may be able to save on FLAREX^®

Patient Terms and Conditions:

Please visit MyEyeSavings.com to acquire and activate your Santen 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 Santen 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 $39. 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 $39. 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 commercial insurance company.
Submit the balance due as a Secondary Submission COB with the patient responsibility amount and a valid Other Coverage Code (OCC).
For eligible commercial patients when the product is covered, submit BIN and OCC 08. For eligible commercial patients when the product is not covered, submit BIN and OCC 03.

For Medicare Part D patients
Patients with approved coverage are ineligible for copay savings. Process the claim to the primary Part D provider.
Patients with declined coverage: Submit this claim as a primary submission with the codes (OCC 0,1). The patient must agree to the program's enrollment requirements, which include opting out of utilizing their plan pharmacy benefits.

For cash-paying patients
Submit this claim as a primary submission with the codes (OCC 0,1).

In the scenarios above, the patient is responsible for the first $39.00. Reimbursement for the balance, up to the program's maximum, will be submitted to the pharmacy.
For pharmacy processing questions, please call 1.316.219.4802.

Program Terms and Conditions:

The Santen 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.

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