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