Home | PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1%

Medicare Part D Eligibility Certification

To obtain your co-pay card, you must agree to the following:

I have Medicare Part D coverage or I am a Medicare Advantage patient. I do not have coverage through Medicaid, Tricare, DOD Tricare, VHA, IHS, SCHIP, or any other state or federal health programs.

I agree to not seek reimbursement from my Medicare or Medicare Advantage prescription plan for my out-of-pocket costs for PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% purchased with the card.

I will not count the cost of PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% toward my deductible or true out-of-pocket cost.

I will purchase all of my prescriptions for PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% before the end of the year using this card, and I will not use my Medicare Part D benefits for PRED FORTE® at any time during this calendar year, even my benefits change.

I will notify my prescription plan that I have purchased PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% outside my benefit by sending the form letter provided with your savings card plan.

I agree to these requirements and accept the Program Terms, Conditions, and Eligibility Criteria below or on back of the card.

Medicare Part D Offer
Program Terms, Conditions, and Eligibility Criteria

1. This offer is valid only for eligible patients and is good for use only with a valid prescription for PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. Depending on your insurance coverage, eligible patients may pay as little as [$50] for up to 6 prescription fills of PRED FORTE®. Check with your pharmacist for your co-pay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. 3. This offer is only valid for patients with Medicare Part D prescription drug insurance (including Medicare Advantage prescription drug plans) in the following instances: (a) the patient’s Medicare Part D prescription drug insurance does not cover PRED FORTE®; or (b) the patient opts out of using their Medicare Part D prescription benefit in conjunction with this offer. The patient is responsible for the full cash payment for the prescription. This offer is not valid for any patients with commercial insurance, uninsured patients, or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE. 4. To be eligible for this offer, a patient must agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for PRED FORTE® purchased with the card. 5. To be eligible for this offer, a patient must agree not to count the cost of PRED FORTE® toward their deductible or true out-of-pocket costs. 6. To be eligible for this offer, a patient must notify their prescription plan that PRED FORTE® has been purchased outside of benefit by sending the form letter provided by ALLERGAN at www.predforte.com/PDFs/PRE123766-PRED-FORTE-Co-pay-Card-Letter.pdf. 7. To be eligible, the patient must agree to use this card with all purchases of prescription PRED FORTE® made prior to [12/31/19]. 8. Offer applies only to prescriptions filled before the program expires on [12/31/2019]. 9. Allergan reserves the right to rescind, revoke, or amend this offer without notice. 10. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies. Offer not valid for prescriptions filled at pharmacies within Massachusetts. 11. Void if prohibited by law, taxed, or restricted. 12. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 13. This card has no cash value and may not be used in combination with any other discount coupon, discount card, rebate, free trial, or similar offer for the specified prescription. 14. This offer is not health insurance. 15. This card expires [12/31/2019]. 16. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about this program, please call 1-877-737-0629.

Pharmacist Instructions for a patient with Medicare Part D or Medicare Advantage: 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. You are prohibited from submitting a claim using this card as a Secondary Payer.

Submit the claim to Change Healthcare using BIN 600426 as a Primary Payer. A valid Other Coverage Code (e.g., 0 or 1) is required. The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from Change Healthcare.
Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Pharmacy Help Desk at 1-800-433-4893.

Program managed by COMP, LLC on behalf of Allergan.

Commercial Insurance Eligibility Certification

To obtain your co-pay card, you must agree to the following:

I am a resident of the United States or Puerto Rico.

I have commercial prescription drug insurance.

I am not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses me for the entire cost of my prescription drugs.

I am not Medicare-eligible.

I am not enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.

I agree to these requirements and accept the Program Terms, Conditions, and Eligibility Criteria below or on back of the card.

Commerical Insurance Offer
Program Terms, Conditions, and Eligibility Criteria

1. This offer is valid only for eligible patients and is good for use only with a valid prescription for
PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% at the time the prescription is filled by the pharmacist and dispensed to the patient. 2. Depending on your insurance coverage, eligible patients may pay as little as [$50] for up to 6 prescription fills of PRED FORTE®. Check with your pharmacist for your co-pay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. 3. This offer is only valid for commercially insured patients. This offer is not valid for use by patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this offer if they are Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. 4. This offer is valid for up to 6 prescription fills. Offer applies only to prescriptions filled before the program expires on [04/30/2020]. 5. Allergan reserves the right to rescind, revoke, or amend this offer without notice. 6. Offer good only in the USA, including Puerto Rico, at participating retail pharmacies. Offer not valid for prescriptions filled at pharmacies within California or Massachusetts. 7. Void if prohibited by law, taxed, or restricted. 8. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 9. This card has no cash value and may not be used in combination with any other discount coupon, discount card, rebate, free trial, or similar offer for the specified prescription. 10. This offer is not health insurance. 11. This card expires [04/30/2020]. 12. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about this program, please call 1-877-737-0629.

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 insurance first, then submit the balance due to Change Healthcare as a Secondary Payer coordination of benefits (COB) with patient responsibility amount and a valid Other Coverage Code, e.g., 8. The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from Change Healthcare.
If you receive an NDC Not Covered or Product Not Covered rejection from the primary insurance, submit the balance due to Change Healthcare as a secondary Payer with an Other Coverage Code of 3.
If you receive a rejection from the primary insurance due to prior authorization (PA) or step edit requirements, contact the provider to initiate the PA/step edit.
Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Pharmacy Help Desk at 1-800-433-4893.

Program managed by COMP, LLC on behalf of Allergan.

CALIFORNIA Commercial Insurance Eligibility Certification

To obtain your co-pay card, you must agree to the following:

I am a resident of the United States or Puerto Rico.

I have commercial prescription drug insurance.

I am not enrolled in a federal- or state-funded prescription drug benefit program, such as Medicare, Medicaid, or any private indemnity or HMO insurance plan that reimburses me for the entire cost of my prescription drugs..

I am not Medicare-eligible.

I am not enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees.

I agree to not seek reimbursement from my commercial insurance prescription plan for my out-of-pocket costs for PRED FORTE® (prenisolone acetate ophthalmic suspension, USP) 1% purchased with the card.

I will not count the cost of PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% toward my deductible or true out-of-pocket cost.

I agree to these requirements and accept the Program Terms, Conditions, and Eligibility Criteria below or on back of the card.

California Commercial Insurance Offer
Program Terms, Conditions, and Eligibility Criteria

1. This offer is valid only for eligible patients and is good for use only with a valid prescription for PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1% at the time the prescription is filled by the pharmacist and dispensed to the patient within the state of California. 2. Eligible patients may pay as little as [$50] for up to 6 prescription fills of PRED FORTE®. Check with your pharmacist for your co-pay discount. Maximum savings limit applies; patient out-of-pocket expense may vary. 3. This offer is only valid for commercially insured patients in the following instances: (a) the patient’s commercial insurance prescription drug plan does not cover PRED FORTE®; or (b) the patient opts out of using their commercial insurance prescription drug plan in conjunction with this offer. The patient is responsible for the full cash payment for the prescription. This offer is not valid for uninsured patients or patients enrolled in Medicare, Medicaid, or other federal or state programs (including any state pharmaceutical assistance programs), or private indemnity or HMO insurance plans that reimburse you for the entire cost of your prescription drugs. Patients may not use this offer if they are Medicare eligible and enrolled in an employer-sponsored health plan or prescription drug benefit program for retirees. 4. To be eligible for this offer, a patient must agree to not seek reimbursement from their commercial insurance prescription plan for their out-of-pocket costs for PRED FORTE® purchased with the card. 5. To be eligible for this offer, a patient must agree not to count the cost of PRED FORTE® toward their deductible or true out-of-pocket costs. 6. To be eligible, the patient must agree to use this card with all purchases of prescription PRED FORTE® made prior to [04/30/2020]. 7. Offer applies only to prescriptions filled before the program expires on [04/30/2020]. 8. Allergan reserves the right to rescind, revoke, or amend this offer without notice. 9. Offer good only for prescriptions filled within the State of California, at participating retail pharmacies. 10. Void if prohibited by law, taxed, or restricted. 11. This card is not transferable. The selling, purchasing, trading, or counterfeiting of this card is prohibited by law. 12. This card has no cash value and may not be used in combination with any other discount coupon, discount card, rebate, free trial, or similar offer for the specified prescription. 13. This offer is not health insurance. 14. This card expires [04/30/2020]. 15. By redeeming this card, you acknowledge that you are an eligible patient and that you understand and agree to comply with the terms and conditions of this offer.

For questions about this program, please call 1-877-737-0629.

Instructions for Pharmacists within the State of California: When you redeem this card, you certify that you have not submitted and will not submit a claim for reimbursement under any commercial insurance prescription plan or federal, state, or other government programs for this prescription. You are prohibited from submitting a claim using this card as a Secondary Payer.

Submit the claim to Change Healthcare using BIN 600426 as a Primary Payer. A valid Other Coverage Code (e.g., 0 or 1) is required. The patient’s out-of-pocket expense will be reduced up to the maximum savings limit for the program. Reimbursement will be received from Change Healthcare.
If you receive an NDC Not Covered or Product Not Covered rejection from the primary insurance, submit the balance due to Change Healthcare as a secondary Payer with an Other Coverage Code of 3.
Valid Other Coverage Code required. For any questions regarding Change Healthcare online processing, please call the Pharmacy Help Desk at 1-800-433-4893.

Program managed by COMP, LLC on behalf of Allergan.