DEXTENZA® Commercial Coverage Program Eligibility Requirements, Terms and Conditions:

The DEXTENZA Commercial Coverage Program is designed to assist eligible patients with their out-of-pocket costs for DEXTENZA.

 

 Eligibility Criteria/Terms and Conditions:

 

  • The value of this Program is exclusively for the benefit of patients and is intended to be used towards patient out-of-pocket drug costs only, including applicable co-payments, coinsurance, and deductibles.
  • The Program will cover the patient’s out-of-pocket cost for DEXTENZA after the insurance has paid its portion, up to a maximum benefit of $555.00.
  • Program benefits are provided to eligible patients with commercial insurance coverage upon completion of a benefit verification by DEXTENZA360 and receipt of a primary insurance Explanation of Benefits (EOB), which shows a patient out-of-pocket responsibility for DEXTENZA.
  • Program is valid ONLY for patients with commercial or private insurance who are prescribed DEXTENZA for an FDA-approved indication.  Patients with government insurance are not eligible for the Program, including, but not limited to, Medicare, Medicaid, Medicare Advantage, VA, DoD, TRICARE, CHAMPVA or any other federally or state-funded government-assisted program.
  • Offer is not valid for use with any other program, discount, or offer involving DEXTENZA or where insurance is paying the entire cost of DEXTENZA. Where third-party reimbursement covers a portion of DEXTENZA, the offer is valid only for the amount of the actual out-of-pocket cost, up to the maximum benefit.
  • The benefit available under the Program is valid for the out-of-pocket cost for the product only. It is not valid for any other out-of-pocket costs (for example, office visit charges, medication administration charges or evaluations) even if such costs are associated with the administration of DEXTENZA.
  • Patient is responsible for all additional costs and expenses once the maximum benefit limit is reached, including additional co-payment and co-insurance amounts.
  • Offer valid in the US and its territories; void where prohibited by law.
  • Patient may not seek reimbursement for all, or any part of the benefit received through this offer and are responsible for making any required reports of utilization of this offer to any insurer, or other third-party who pays any part of the cost of DEXTENZA.
  • Program is not health insurance.
  • Offer is not conditioned on any past or future purchases. Ocular Therapeutix reserves the right to rescind, revoke, terminate or amend the Program at any time, without notice.
  • An EOB from the patient’s commercial/private insurance must be submitted within 180 days of the date of service for the patient to receive out-of-pocket assistance. The EOB must reflect the patient’s out-of-pocket cost for DEXTENZA and submission of the claim by the patient’s physician for the cost of the medication.
  • You must be 18 years of age or older to redeem this offer.

 

Program Eligibility Requirements:

 

  • Patient must be prescribed DEXTENZA for an FDA-approved indication
  • Patient must be enrolled in the DEXTENZA360 Program
  • Patient must have a commercial insurance plan that covers the cost of DEXTENZA
  • Patient must not have government insurance including, but not limited to, Medicare, Medicaid, Medicare Advantage, VA, DoD, TRICARE, CHAMPVA or any other federally or state-funded government-assisted program
  • Offer is not valid for cash-paying patients
  • Eligible patients must have an out-of-pocket cost for DEXTENZA and be administered the product prior to the expiration date of the Program
  • No Income eligibility required
  • Patient must be 18 years or older and a resident of the US or US Territory