Please enter the date of birth of the patient who will use this coupon.

Please enter patient date of birth.

Please enter the 5-digit zip code of the residence of the patient who will use this coupon.

Please enter patient zip code.

Please enter the mobile phone number of the patient who will use this coupon.

Please enter patient phone number.

I have Medicare Part D coverage, or I am a Medicare Advantage patient. I do not have coverage through Medicaid, TRICARE, DOD Tricare, Veterans Administration or Department of Defense health coverage, the Puerto Rico Government Health Insurance Plan or any other federal or state healthcare benefits program.

Yes

No

Please make selection.

I agree to not seek reimbursement from my Medicare Part D or Medicare Advantage prescription plan for my out-of-pocket costs for INVELTYS purchased with the coupon. I will not count the cost of prescriptions toward my deductible or true out-of-pocket cost.

Yes

No

Please make selection.

I will purchase all of my prescriptions for INVELTYS before the end of the year using this coupon, and I will not use my Medicare Part D or Medicare Advantage benefits for prescriptions at any time during this calendar year, even if my benefits change.

Yes

No

Please make selection.

I will notify my prescription plan that I have purchased INVELTYS outside my benefit by sending the form letter provided by Alcon to the plan.

Yes

No

Please make selection.

Please confirm that you have read, understand, and will comply with the terms and conditions of the program; that you currently meet all eligibility criteria; and have read and agree with the Privacy Policy.

Yes

No

Please make selection.

DIRECT ACCESS SUPPORT PROGRAM

Medicare Part D patients may pay

as little as $60^* per bottle

DIRECT ACCESS SUPPORT PROGRAM

Medicare Part D patients may pay

as little as $60* per bottle

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as little as $60^* per bottle