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Eyevance® is committed to helping all patients have affordable access to ZERVIATE®

To learn more about ZERVIATE access, visit www.myeyesavings.com

Eligible commercially insured patients may PAY AS LITTLE AS $49


Eligible Medicare patients, cash-paying patients, and patients denied coverage may PAY AS LITTLE AS $59

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.

INDICATIONS AND USAGE

ZERVIATE® (cetirizine ophthalmic solution) 0.24% is a histamine-1 (H1) receptor antagonist indicated for treatment of ocular itching associated with allergic conjunctivitis.

DOSAGE AND ADMINISTRATION

Instill one drop of ZERVIATE in each affected eye twice daily (approximately 8 hours apart).

IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS

Contamination of Tip and Solution: As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle or tip of the single-use container to avoid injury to the eye and to prevent contaminating the tip and solution. Keep the multi-dose bottle closed when not in use. Discard the single-use container after using in each eye.

Contact Lens Wear: Patients should be advised not to wear a contact lens if their eye is red. ZERVIATE should not be instilled while wearing contact lenses. Remove contact lenses prior to instillation of ZERVIATE. The preservative in ZERVIATE, benzalkonium chloride, may be absorbed by soft contact lenses. Lenses may be reinserted 10 minutes following administration of ZERVIATE.

ADVERSE REACTIONS

The most commonly reported adverse reactions occurred in approximately 1%–7% of patients treated with either ZERVIATE or vehicle. These reactions were ocular hyperemia, instillation site pain, and visual acuity reduced.

Please see the Full Prescribing Information.

INDICATIONS AND USAGE

ZERVIATE® (cetirizine ophthalmic solution) 0.24% is a histamine-1 (H1) receptor antagonist indicated for treatment of ocular itching associated with allergic conjunctivitis.

DOSAGE AND ADMINISTRATION

Instill one drop of ZERVIATE in each affected eye twice daily (approximately 8 hours apart).

IMPORTANT SAFETY INFORMATION

WARNINGS AND PRECAUTIONS

Contamination of Tip and Solution: As with any eye drop, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle or tip of the single-use container to avoid injury to the eye and to prevent contaminating the tip and solution. Keep the multi-dose bottle closed when not in use. Discard the single-use container after using in each eye.

Contact Lens Wear: Patients should be advised not to wear a contact lens if their eye is red. ZERVIATE should not be instilled while wearing contact lenses. Remove contact lenses prior to instillation of ZERVIATE. The preservative in ZERVIATE, benzalkonium chloride, may be absorbed by soft contact lenses. Lenses may be reinserted 10 minutes following administration of ZERVIATE.

ADVERSE REACTIONS

The most commonly reported adverse reactions occurred in approximately 1%–7% of patients treated with either ZERVIATE or vehicle. These reactions were ocular hyperemia, instillation site pain, and visual acuity reduced.

Please see the Full Prescribing Information.