SAVE NOW ON BIN:004682 PCN:CN GRP:EC34004007 ID#:28599888061 OFFER EXPIRES ON: 3/31/2015 Eligible patients will pay no more than $25 for a prescription Maximum benefit per bottle is $85. Show this rebate to your pharmacist for instant savings* on MOXEZA® Solution *Terms and Conditions: The program is offered by Alcon and applies only to MOXEZA® (moxifloxacin HCl ophthalmic solution) 0.5% as base prescriptions filled on or before 03/31/2015 for which patient has: (1) private insurance copay requirement of $25 or more, or (2) no insurance. This offer is not valid for patients who are enrolled in Medicare Part D, Medicaid, Medigap, VA, DOD, Tricare, or any other government-run or government-sponsored health care program with a pharmacy benefit. Each patient pays no more than $25 in out-of-pocket expenses for MOXEZA® Solution. Maximum benefit per bottle is $85. Offer good for up to three (3) 3mL bottles of MOXEZA® Solution for a single patient. Use of the card does not obligate the patient to use or continue using any Alcon product. No other purchase is necessary. You may use the card at any participating pharmacy in the United States. The Card: (a) may not be combined with any other savings, discount, free trial, or other similar offer for the same prescription; (b) is not transferrable, is void if reproduced, and has no cash value; and (c) is not health insurance. Limit one (1) card per patient. Alcon reserves the right to rescind, revoke or amend this offer without notice and to deny payment for non-compliance with these terms. This offer expires on March 31, 2015. Use of this card is subject to applicable state and federal laws. Eligibility: By using the card, you acknowledge that you currently meet the following eligibility criteria, you have: a valid prescription for MOXEZA® Solution; no insurance or are subject to a private insurance copay requirement for your prescription; are not enrolled in government-run or government-sponsored health care program with a pharmacy benefit; are at least 18 years old; and reside in the United States. No purchase necessary and there are no membership fees. Licensed to Alcon by Bayer Pharma AG © 2014 Novartis 3/14 MOX14034RB DROPS101.com Patient Instructions: Present your card to your pharmacist along with an eligible prescription for MOXEZA® Solution each time you fill your prescription. The prescriber ID# must be identified on the prescription. This offer is not valid for patients who are enrolled in Medicare Part D, Medicaid, Medigap, VA, DOD, Tricare, or any other government-run or government-sponsored healthcare program with a pharmacy benefit. It is important to make sure that you comply with your health insurer’s policies about copay cards. In addition, you agree that you will disclose this offer to your private insurer, if any. You are responsible for any applicable taxes. If you have any questions, please call (866) 504-6840. Pharmacist instructions: By accepting the card, you agree to the terms and conditions of the card. You may not advertise or otherwise use the card to promote the services of your pharmacy. You agree that you will comply with the policies of, will inform as required, the patient’s insurer and not request payment from Alcon where copay cards are prohibited by the patient’s insurer or by applicable law. You may not seek reimbursement from a patient or health insurer for amounts provided by Alcon towards the patient’s copay. Please be aware that Alcon may deny payment if you do not comply with the terms of this offer. Pharmacist Instructions for a Patient Paying with an Eligible Third Party: Submit the claim to the primary Third Party Payer first, then submit the balance due to Therapy First Plus as a Secondary Payer as a copay only billing using a valid Other Coverage Code (e.g., 8). The patient is responsible for $25 copay and Alcon will pay up to $85 maximum. Reimbursement will be received from Therapy First Plus. Pharmacist Instructions for a Cash Paying Patient: Submit this claim to Therapy First Plus. A valid Other Coverage Code (e.g., 1) is required. The patient is responsible for $25 copay and Alcon will pay up to $85 maximum. Reimbursement will be received from Therapy First Plus. For any questions regarding Therapy First Plus online processing, please call the Help Desk at 1-800-422-5604.