My Tears, My Rewards® Program Terms and Conditions
RESTASIS® (Cyclosporine Ophthalmic Emulsion) 0.05% My Tears, My Rewards®
is an incentive and counseling program offered to eligible enrollees free of
charge. You can enroll by obtaining a RESTASIS® Advantage Patient Support Pack
by request through telephone, web, reply to a printed offer, or participating physicians.
Eligibility
This Program cannot be offered to individuals whose prescriptions are paid for in
part or in whole by Medicare, Medicaid, or any similar federal or state healthcare
program, including any state medical or pharmaceutical assistance programs.
Offer void where prohibited by law, taxed, or restricted.
You are responsible for reporting receipt of a rebate to any private insurer that
pays for, or reimburses you for, any part of the prescription filled.
This Program cannot be combined with other offers. One per consumer.
This Program is offered only in the United States and Puerto Rico.
MTMR Card Savings
The MTMR Card must be activated by calling an automated voice response system. You
must provide a valid mailing and e-mail address to receive e-mail communications
that offer guidance for treatment and apprise you of cost savings.
To receive credit toward your prescription savings, the MTMR Card must be presented
when purchasing a RESTASIS® Ophthalmic Emulsion prescription.
The actual rebate savings amount you are entitled to is equal to your out-of-pocket
payment—your co-pay—for each prescription of RESTASIS®, up to the
specified rebate savings amount for each refill, whichever is less.
If you use your MTMR Card to fill your RESTASIS® Ophthalmic Emulsion prescription
within 10 days of this activation, you may be eligible to receive an additional
$10 savings off your first prescription.
MTMR (30-day) Program
For each 30-day RESTASIS® prescription you may be eligible to receive up to
$10 off refills 1, 2, 3, 5, 6, 7, 9, 10, and 11 and up to $75 off on refills 4,
8, and 12.
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 refill.
Only RESTASIS® Ophthalmic Emulsion prescriptions for a
30-day supply of 2 trays—60 vials total can be redeemed toward these savings.
No other refill quantities will qualify.
MTMR (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 up to an additional $10 in savings if you refill a 90-day
prescription within 100 days of your prior 90-day prescription refill.
Only RESTASIS® Ophthalmic Emulsion prescriptions for a 90-day supply of 6 trays—180
vials total can be redeemed toward these savings. No other refill quantities will
qualify.
RESTASIS® My Tears, My Rewards® Program for Mail-Order Pharmacy
If your pharmacy or mail-order pharmacy does not accept the MTMR Card, you can submit
a completed Independent Rebate Redemption form and required pharmacy receipt for
a 30-day or 90-day supply of RESTASIS® by mail, with proper address and postage,
to:
RESTASIS® Claims Processing Dept
P.O. Box 377
Edison, NJ 08818-0377
The applicable benefit amount will be loaded onto your MTMR Card and you will be
notified of the amount added.
MTMR Card Expiration and Re-Enrollment
Your MTMR Card is valid for 1 year from the date of the card's first use for your
initial RESTASIS® prescription, or on the last day of the expiration month and
year designated on your MTMR Card, whichever comes first.
After the expiration of your MTMR Card, you may be entitled to re-enroll pursuant
to program rules at that time.
Allergan reserves the right to revise or discontinue this program at any time and
without prior notice or recourse.
Approved Use
RESTASIS® Ophthalmic Emulsion is a prescription medicine that helps increase
your eyes' natural ability to produce tears, which may be reduced by inflammation
due to Chronic Dry Eye. RESTASIS® did not increase tear production in patients
using anti-inflammatory eye drops or tear duct plugs.
Important Safety Information
Do not use RESTASIS® Ophthalmic Emulsion if you are allergic to any of the ingredients.
To help avoid eye injury and contamination, do not touch the vial tip to your eye or other surfaces.
RESTASIS® should not be used while wearing contact lenses. If contact lenses are worn,
they should be removed prior to the use.
The most common side effect is a temporary burning sensation. Other side effects
include eye redness, discharge, watery eyes, eye pain, foreign body sensation, itching,
stinging, and blurred vision.
You are encouraged to report negative side effects of prescription drugs to the
FDA. Visit www.fda.gov/medwatch,
or call 1-800-FDA-1088.
Click here for
Product Information for RESTASIS® Ophthalmic Emulsion.
APC40AB13
