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BromSite® Co-Pay Terms and Conditions:

To participate in the BromSite® (bromfenac ophthalmic solution) 0.075% Co-Pay Program (“Program”), you must present this card, along with a valid prescription for BromSite® to your pharmacist. Patients with commercial health insurance who qualify to participate can pay as little as $35 per bottle, for four prescriptions, with a maximum benefit of $400. Patients without commercial insurance who qualify to participate can pay as little as $50 per bottle, for four prescriptions, with a maximum benefit of $400. Patients without commercial insurance who have prescription drug coverage under Medicare Part D 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 BromSite®, or report any amount paid for BromSite® as part of their “true out of pocket expenses” under Medicare Part D. Part D patients who qualify to participate can pay as little as $60 per bottle, for four prescriptions, with a maximum benefit of $844. Enrollment is subject to the Eligibility Rules and Terms and Conditions, stated below. If you have any questions regarding Eligibility, the Terms and Conditions, or to discontinue participation, please call 1.855.379.2324 (8:00 am-8:00 pm EST, Monday-Friday).

Eligibility Rules

  • To participate in this Program, you must have commercial health insurance and be a resident of the United States, Puerto Rico Guam, or the Virgin Islands.
  • Patients that have prescription drug coverage under Medicare Part D may be eligible for this program provided that they acknowledge that, by participating in the program, they will not seek any prescription coverage or reimbursement from their insurer for the cost of BromSite®, or report any amounts paid for BromSite® as part of their “true out of pocket expenses” under Medicare Part D.
  • The following patients are ineligible for this Program.
    • Patients covered under Medicaid (including Medicaid patients enrolled in a Medicaid Managed Care Plan or a qualified health plan purchased through a health insurance exchange marketplace established by a state government or the federal government).
    • Patients covered by Medicare or a Medicare Advantage plan (regardless of whether a specific prescription is covered).
    • Patients covered by TRICARE, CHAMPUS, Puerto Rico Government Health Insurance Plan or any other state or federal medical or pharmaceutical benefit program or pharmaceutical assistance program.

Terms and Conditions

  • You agree to not to seek any reimbursement for all or any part of the co-pay assistance received through the Program. By using this card, you are certifying that you understand the Eligibility Rules and Terms and Conditions, that you have responded truthfully to questions when activating the card, and that you will disclose and report, your receipt of any Program benefits to your insurer, health plan, or any third party that pays or reimburses you for the cost of medications, if required.
  • This offer may be rescinded, revoked or cancelled at any time, without further notice and the rules may be amend at any time, without further notice.

Disclosures

  • This Program is not insurance.
  • The Program is void where prohibited by law, taxed, or restricted. Any benefit provided is not transferable and cannot be combined with any other program, free trial, discount, prescription savings card, or other offer. No purchase, other than for a BromSite® prescription is required to participate.
  • Personal data that you provide to the Program may be collected, analyzed, and shared with the program sponsor for market research and other lawful purposes but only in aggregated and de-identified form.


To the Patient:
You must activate and present this card to the pharmacist with a valid prescription to participate in this program. If you have questions regarding your eligibility or benefits, or if you wish to discontinue your participation, call the Sun Pharma BromSite® Copay Card Activation program at 1.855.379.2324 (8:00 am-8:00 pm EST, Monday-Friday). For patients whose BromSite® prescriptions are covered by commercial insurance, use of this card may reduce your copayment responsibility to as little as $35. For patients whose BromSite® prescriptions are not covered by either commercial or government insurance, use of this card may reduce your cost for BromSite® to as little as $60. This program is subject to overall maximum support amounts, and is valid for up to 3 prescriptions. This coupon is not valid for Federal health care beneficiary prescriptions that are eligible to be reimbursed, in whole or in part, by Medicaid, Medicare, Tricare or other federal or state healthcare programs (including any state prescription drug assistance programs). Patients that have prescription drug coverage under Medicare Part D 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 BromSite®, or report any amounts paid for BromSite® as part of their "true out of pocket expenses" under Medicare Part D. 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 the card.

To the Pharmacist: 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.

  • Submit transaction to McKesson Corporation using BIN #610524
  • If primary commercial prescription insurance exists, input card information as secondary coverage and transmit using the COB segment of the NCPDP transaction. Applicable discounts will be displayed in the transaction response.
  • Acceptance of this card and your submission of claims for the Sun Pharma BromSite® Copay Card Activation program are subject to the LoyaltyScript® program Terms and Conditions posted at www.mckesson.com/mprstnc
  • Sun Pharma reserves the right to rescind, revoke, or change this offer at any time. The LoyaltyScript® card is not valid for use with any other prescription drug discount or cash cards for BromSite®. Claims submitted utilizing the program are subject to audit or validation.
  • For questions regarding setup, claim transmission, patient eligibility or other issues, call the LoyaltyScript® for Sun Pharma BromSite® Copay Card Activation program at 1.855.379.2324 (8:00 am-8:00 pm EST, Monday-Friday).
    Sun Pharma reserves the right to rescind, revoke or amend this offer at any time.