Not an actual card
ELIGIBILITY REQUIREMENTS
An eligible patient must:
Program Terms, Conditions, and Eligibility Criteria: 1. This offer is valid only for patients 18 years of age or older who have commercial insurance coverage for OZURDEX® (dexamethasone intravitreal implant) 0.7 mg. 2. This offer is not valid for use by patients receiving prescription reimbursement under any federal, state, or government-funded healthcare programs (e.g., Medicare, Medicare Advantage, Medigap, Medicaid, TRICARE, Department of Defense, or Veterans Affairs programs); private indemnity or HMO insurance plans that reimburse patients for the entire cost of their prescription drugs; or where prohibited by the patient’s health insurance provider. If at any time a patient begins receiving prescription drug coverage under any federal, state, or government-funded healthcare program, patient will no longer be eligible for this offer and must call IQVIA Inc. at 1-866-249-8003 to stop program participation. This offer is not valid for cash-paying patients. 3. Depending on insurance coverage, most eligible insured patients may pay as little as $0 per eye. This offer applies to the implant only and does not apply to costs for any other medication, procedure, or diagnostic service. Check with healthcare provider and insurance plan for discount. Maximum reimbursement limit of $5000.00 per patient per current program period applies; patient out-of-pocket expense will vary. 4. Offer applies only to implants administered during the current program period of January 1, 2023 through December 31, 2023. Savings requests and required supporting documentation must be uploaded to allerganeyecue.com, sent by fax to 1.866.676.4069, or emailed to [email protected] within 180 days after the date of service, i.e., the date product is administered to the patient. 5. Patients and healthcare providers may not seek reimbursement for value received from the OZURDEX Savings Program from any third-party payers. 6. Allergan, an AbbVie company, reserves the right to rescind, revoke, or amend this offer without notice. 7. Offer good only in the USA, including Puerto Rico and Guam. Patients residing in or receiving treatment in certain states may not be eligible to participate in this program. 8. Void if prohibited by law, taxed, or restricted. 9. This offer is not transferable. The selling, purchasing, trading, or counterfeiting of this offer is prohibited by law. 10. This offer has no cash value and may not be used in combination with any other discount, coupon, rebate, free trial, or similar offer for the specified prescription. 11. This offer is not health insurance. 12. Offer expires December 31, 2023. 13. By redeeming this offer, patient represents they meet the eligibility criteria above and patient understands and agrees to comply with the terms and conditions of this offer.
For questions about this program, please call 1-866-OZURDEX (1-866-698-7339) or email [email protected].
Pharmacist Instructions for a Patient with an Eligible Third-Party Payer: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any federal, state, or other government programs for this prescription. Submit the claim to the primary third-party payer first, then submit the balance due to IQVIA (OPUS) using BIN #601341 as a Secondary Payer COB (coordination of benefits) with patient responsibility amount and a valid Other Coverage Code (8). The patient's out-of-pocket expense will be reduced up to the maximum reimbursement limit for the program. Reimbursement will be received from IQVIA. For any questions regarding online processing, call the Help Desk at 1-800-364-4767.
Program managed by IQVIA Inc. on behalf of Allergan, an AbbVie company.
