For more information, please go to www.CEQUA.com.

To participate in the CEQUA™ (cyclosporine ophthalmic solution) 0.09% Co-Pay Program (“Program”), you must present this card, along with a valid prescription for CEQUA to your pharmacist. Patients with commercial health insurance who qualify to participate can pay as little as $10 for 60 vials (1 box) of CEQUA, with a maximum annual benefit of $3,500 per calendar year. 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 855-268-1426 (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.
  • 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, a Medicare Part D or 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.
    • Patients with no insurance.

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  • This offer may be rescinded, revoked or cancelled at any time, without further notice and the rules may be amend at any time, without further notice.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 CEQUA 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.

 

WHAT IS CEQUA?

CEQUA™ (cyclosporine ophthalmic solution) 0.09% is a topical solution that helps to increase the production of natural tears in your eye. Dry eye disease may affect the ability of your eyes to produce its own tears.


WHAT SHOULD I KNOW ABOUT CEQUA?

Do not use CEQUA if you are allergic to any of its ingredients. Be careful not to allow the vial tip to touch your eye or any surfaces, to help avoid potential eye injury or contamination of the product.

CEQUA should not be used while wearing contact lenses. If contact lenses are worn, they should be removed prior to using CEQUA and may be reinserted after 15 minutes.

Put one drop of CEQUA twice daily (approximately 12 hours apart) into each eye using a single-use vial. The solution should be used immediately after opening, and discard the vial and remaining contents immediately after using.

The most common side effects that may be experienced while using CEQUA include: eye pain after administering drops and eye redness. Other side effects reported were eye irritation, eyelid inflammation, headache, and urinary tract infection.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.