TERMS AND CONDITIONS

By using the XIIDRA My Savings Program, you confirm that you understand and agree to comply with the following Terms and Conditions of this offer:

• Must be 18 years of age or older to redeem this offer.
• This offer is only valid for eligible patients with private/commercial insurance.
• This offer is not valid for any patient with health insurance that allows for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state healthcare programs.
• Reimbursement limitations apply. Patient is responsible for all additional costs and expenses after reimbursement limits are reached, including additional copayment and coinsurance amounts.
• Eligible, commercially insured patients using the copay card pay $0 for their first prescription of Xiidra. $0 first fill available for prescriptions up to 90 days. After the first fill, eligible, commercially insured patients may pay as little as $0 for prescriptions of Xiidra, subject to a monthly savings of $250 for each 30-day prescription and $750 for each 90-day prescription. The copay card can be
• Patients with high deductible or coinsurance health plans may pay more than $0. For questions, please call 1-877-494-4372.
• This offer is not valid for any person who is 65 years of age or older without private/commercial insurance.
• This offer shall be applied only toward the cost of an eligible prescription product and not toward ancillary services or treatment costs.
• This offer is good for use only with the products identified herein. No other purchase is necessary.
• You agree not to seek reimbursement for all or any part of the benefit received through this offer and are responsible for making any required reports of your use of this offer to any insurer or other third party who pays any part of the prescription filled.
• This offer is not valid when the entire cost of your prescription drug is eligible to be reimbursed by your private/commercial insurance plan or other private/ commercial health or pharmacy benefit programs.
• This offer is good only in the United States of America (including the District of Columbia, Puerto Rico, Guam and the U.S. Virgin)
• This offer is not valid where prohibited, taxed, or otherwise restricted.
• You must present this coupon along with your prescription to participate in this program.
• You must activate your coupon before use. Please activate online at xiidra.copaysavingsprogram.com or on the phone by calling
• This offer cannot be redeemed at government-subsidized clinics.
• This offer is not health insurance.
• The selling, purchasing, trading, or counterfeiting of this coupon is prohibited by law. Void if reproduced.
• This offer is not valid with any other savings, free trial, or other similar offers for the specified prescription. This coupon has no cash value. No cash back.
• This offer is not transferable.
• Bausch + Lomb reserves the right to rescind, revoke, terminate, or amend this offer at any time, without notice.
• When you use this offer, you are certifying that you understand and agree to comply with the program rules, regulations, eligibility
• For questions call: 1-877-494-4372.