I do not have a Rocklatan^®/Rhopressa^® Savings Card and would like to download one now.

We need to know a little more about you. Please fill out the information and answer the questions below.

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*First name: First Name is required

*Last name: Last Name is required

*Address1: Address is required

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*City: City is required

*State:State is required

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*Date of birth:

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*Are you eligible for reimbursement of prescriptions (in whole or in part) under any federal, state or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, or any other federal or state healthcare programs?

Yes

*Are you 18 years of age or older?

Yes

By clicking “Submit”, I confirm that I have read and understand the Eligibility Criteria, Terms and Conditions contained above, and that the patient who will use the savings card meets all eligibility criteria and will comply with all terms and conditions of the program.

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*Eligibility Criteria/Terms and Conditions

By using the Rocklatan^®/Rhopressa^® Savings Card, you confirm that you understand and agree to comply with the following terms and conditions of this offer:

This offer is valid for eligible residents of the United States only (including the District of Columbia) at participating retail pharmacies. This offer is void in U.S. territories including, but not limited to, Puerto Rico.
This offer is only valid for patients with commercial insurance.
This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare, Medicaid, TRICARE, CHAMPUS, or any other federal or state health care programs.
This offer may not be combined with any savings, discount, trial or similar offer for the same prescription
No other purchase is necessary.
This card is not health insurance.
By using this offer, the patient certifies that he or she will comply with the terms of his or her health insurance contract requiring notification to his or her payor of the existence and/or value of this offer.
You must be 18 years of age or older to redeem this offer.
Eligible commercially insured patients may pay as little as $25 per 30-day, 60-day, or 90-day supply. Patient pay amount may vary dependent upon commercial insurance coverage for ROCKLATAN^® or RHOPRESSA^®. Maximum savings limit applies; patient out-of-pocket expense may vary. Offer valid up to 12-month qualifying prescriptions.
It is illegal to (or offer to) sell, purchase, trade, or counterfeit this offer.
This offer is not transferable.
Offer void where prohibited by law.
This offer and coupon expire on 12/31/2021.
Aerie Pharmaceuticals reserves the right to rescind, revoke, terminate, or amend this offer without notice at any time.
You understand and agree to comply with the terms and conditions of this offer as set forth above.
For questions call: 1-844-807-9706.