Terms and Conditions:

• For patients whose prescriptions are covered by commercial insurance, use of this card may reduce your copayment so that you may pay as little as $0 for (Vevye & Verkazia).
• For patients whose prescriptions are covered by commercial insurance, use of this card may reduce your copayment so that you may pay as little as $59 for (Tobradex ST, Flarex, Zerviate, Vigamox, and Ilevro).
• For patients whose prescriptions are not covered by either commercial insurance or Medicare, use of this card may reduce your cost for prescriptions to as little as $79 for (Vevye & Verkazia).
• For patients whose prescriptions are not covered by either commercial insurance or Medicare, use of this card may reduce your cost for prescriptions to as little as $59 for (Tobradex ST, Flarex, Zerviate, Vigamox, and Ilevro).
• This card is not valid for prescriptions paid for in part or full by Medicare, Medicaid, Tricare, DOD, VA, or any state or federally funded pro- gram.
• By enrolling in the Harrow Savings Program you certify to the following: (1) Your Medicare plan does not cover your Harrow prescription medication; (2) you will not seek any prescription coverage or reimbursement from your Medicare plan for the the cost of the Harrow pre- scriptions received through this offer or report any amounts paid in connection with this offer toward your True Out-of-Pocket (TrOOP) costs under your plan; and (3) that you will purchase all Harrow prescriptions covered under this offer during the calendar year by using the Harrow Savings Program and will not use your Medicare benefits even if your benefits change.
• This program is subject to overall maximum support amounts.
• 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 only good in the United States of America (including the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands).
• You must present this coupon along with your prescription to participate in this program.
• This offer is not health insurance.
• The selling, trading, or counterfeiting of this coupon is prohibited by law. Void if reproduced.
• This offer is not transferable.
• When you use this offer, you are certifying that you understand and agree to comply with the program rules, regulations, eligibility requirements, and Terms and Conditions.
• Harrow Health reserves the right to rescind, revoke, or amend this offer at any time

Pharmacist Instructions:

For Commericially Insured Patients

• Submit the claim to the primary commercial insurance company.
• Submit the balance due as a Secondary Submission COB with the patient responsibility amount and a valid Other Coverage Code (OCC).
• For eligible commercial patients when the product is covered, submit BlN and OCC 08. For eligible commercial patients when the product is not covered, submit BlN and OCC 03.

For Cash Paying Patients

• For a cash-paying patient, submit the claim as primary with a valid other coverage code (OCC 0,1).
• ln the scenarios above, the patient is responsible for the first $79.00. Reimbursement for the balance, up to the program's maximum, will be submitted to the pharmacy.
• For pharmacy processing questions, please call 1-316-219-4495

For Medicare Patients

• Patients with approved coverage are ineligible for copay savings. Process the claim to the primary Medicare provider.
• Patients with declined coverage: Submit this claim as a primary submission with the codes (OCC 0,1). The patient must agree to the program's enrollment requirements, which include opting out of utilizing their plan pharmacy benefits.

Program Terms and Conditions

• When you process this card, you certify 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 or similar federal or state programs including any state medical pharmaceutical assistance program for this prescription.
• The Harrow Copay Savings Program card is not valid for use with any other prescription drug discount or cash cards for FLAREX^®, TOBRADEX^® ST, ZERVIATE^®, VEVYE^®, VIGAMOX, ILEVRO, VERKAZIA. Claims submitted utilizing the program are subject to audit or validation.
• Harrow reserves the right to rescind, revoke, or amend this offer at any time.