ACTIVATE FOR Alcon SIMBRINZA® Co-Pay Card SAVINGS PROGRAM*



* Limitations apply. Valid only for those with private insurance. The Alcon SIMBRINZA® Co-Pay Card Program includes the Co-Pay card and Rebate. Eligible, commercially insured patients may pay as little as $30 in out of pocket expenses for SIMBRINZA® with a maximum benefit of $2,000 per calendar year. Patients must be 16 years or older to be eligible. Patient is responsible for any costs once limit is reached in a calendar year. Program not valid (i) under Medicare, Medicaid, TRICARE, VA, DoD, or any other federal or state health care program, (ii) where patient is not using insurance coverage at all, or (iii) where the patient's insurance plan reimburses for the entire cost of the drug. The value of this program is exclusively for the benefit of patients and is intended to be credited towards patient out-of-pocket obligations and maximums, including applicable co-payments, coinsurance, and deductibles. Program is not valid where prohibited by law. Patient may not seek reimbursement for the value received from this program from other parties, including any health insurance program or plan, flexible spending account, or health care savings account. Patient is responsible for complying with any applicable limitations and requirements of their health plan related to the use of the Program. Valid only in the United States and Puerto Rico. This Program is not health insurance. Program may not be combined with any third-party rebate, coupon, or offer. Proof of purchase may be required. Alcon reserves the right to rescind, revoke, or amend the Program and discontinue support at any time without notice.


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In order to be eligible for co-pay savings, please read and agree to the following statements:


By using this co-pay card, you acknowledge and confirm that, at the time of usage, the card is valid only for those with commercial insurance. Up to a $2,000 annual cap. Offer not valid under Medicare, Medicaid, or any other federal or state program, for cash-paying patients, where product is not covered by patient's commercial insurance, or where plan reimburses the patient for the entire cost of your prescription drug. Read More Offer is not valid where prohibited by law. Valid only in the US and Puerto Rico. Limitations may apply to California and Massachusetts residents. This program is only valid for those patients 16 years and older. This program is not health insurance. Offer may not be combined with any other rebate, coupon, or offer. This card is the property of Alcon, and must be returned upon request. Alcon, reserves the right to rescind, revoke, or amend the program without notice. You certify responsibility for complying with applicable limitations, if any, of any commercial insurance and reporting receipt of program rewards, if necessary, to any commercial insurer. When the patient uses this offer, you certify that the patient understands the program rules, regulations, and terms and conditions, and that the patient will disclose and report the use of this offer as may be required by patient's insurer. The patient is not eligible if the patient is a cash payer or if prescriptions are paid by any federal or state program, or where prohibited by law; and the patient will otherwise comply with the terms and conditions above. The Alcon SIMBRINZA® Co-Pay Card requires annual review of the program eligibility. The information you/the patient provide may be used to contact the patient about this program. Close