Patient Savings Program

Be sure to let your patients know that they may be eligible to pay no more than $10 for a one month supply of LACRISERT^® by presenting to their pharmacist a copay assistance card that you can give them or by presenting a coupon that they can download and print directly from this site. Please direct your patients to this site to retrieve a coupon or order your own stock of copay assistance cards that you can give them by using this form. Offer is subject to eligibility with maximum discount of $100, and may be used for 12 prescription fills for LACRISERT^®. Patients can visit www.lacrisert.com for more information.

Indications and Usage

LACRISERT^® is indicated in patients with moderate to severe Dry Eye syndromes, including keratoconjunctivitis sicca. LACRISERT^® is indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions. LACRISERT^® is also indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions.

Important Safety Information

LACRISERT^® is contraindicated in patients who are hypersensitive to hydroxypropyl cellulose. Instructions for inserting and removing LACRISERT^® should be carefully followed. If improperly placed, LACRISERT^® may result in corneal abrasion. Because LACRISERT^® may cause transient blurred vision, patients should be instructed to exercise caution when driving or operating machinery. Patients should be cautioned against rubbing the eye(s) containing LACRISERT^®.

The following adverse reactions have been reported, but were in most instances, mild and temporary: transient blurring of vision, ocular discomfort or irritation, matting or stickiness of eyelashes, photophobia, hypersensitivity, eyelid edema, and hyperemia.

Eligibility Terms:

Coupon not valid for prescriptions reimbursed in whole or in part under Medicaid, Medicare, including Medicare Advantage and Part D prescription drug plans, or any other federal or state program (including state pharmaceutical assistance programs) or where prohibited, taxed, or otherwise restricted. Coupon is not valid in Massachusetts, except for cash pay patients.
Good for up to 12 uses.
Valeant Ophthalmology, a division of Valeant Pharmaceuticals North America LLC reserves the right to rescind, revoke or amend this offer without notice.
Offer may not be combined with any other rebate, coupon, free trial, or similar offer. Coupon has no cash value. No cash back.
Patients understand and agree to comply with the terms and conditions of this offer as set forth here.

Dear Pharmacist:

RESTAT has been authorized to reimburse you up to $100.00 plus an administration fee of $2.00 for processing this certificate, after the patient pays the first $10 when accompanied by a prescription for LACRISERT®. This claim may be submitted electronically through RESTAT or by mail. For reimbursement, follow the instructions listed below. Retain a copy of the coupon and file with the prescription for auditing purposes; return the original coupon to the patient. Please remember to restore patient profile to primary PBM after claim submission.

This claim may be submitted one of the following two ways:

This claim may be submitted electronically through RESTAT. Submit all claims in NCPDP standard 5.1. Secondary processing should follow NCPDP standards for Copay Only billing using coverage code 8 (OCC 8). If you have any questions regarding electronic submission, please call the RESTAT help desk at 1-866-450-3277.

If you are unable to process this claim electronically or through your standard “paper claim” format, please return the coupon to the patient and instruct the patient to mail this coupon, along with a duplicate pharmacy label or pharmacy receipt which must include the following information: drug name, the drug quantity, the prescription number, the fill date, the name and address of the pharmacy, the prescribing physician, the patient’s name, and the co-pay amount paid. In addition to this information, please instruct the patient to include the patient’s return address and to mail this information to RESTAT, 11900 West Lake Park Drive, Milwaukee, WI 53224, for prompt payment.

Call 1-866-450-3277 with processing questions.

LAC073-1211