1^st Rx and Eligible Refills

Eligibility Criteria/Terms and Conditions

By using the Bausch + Lomb Copay Program, you confirm that you understand and agree to comply with the following terms and conditions:

• For MIEBO® (perfluorohexyloctane ophthalmic solution), Xiidra® (lifitegrast ophthalmic solution) 5%, VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024%, and TIMOPTIC in OCUDOSE® (timolol maleate ophthalmic solution) this copay card is valid for up to twelve (12) fills per patient in a 12-month period. For all other brands, this copay card is valid for up to six (6) fills per product per patient in a 12-month period.
• Reimbursement limitations apply. Patient is responsible for all additional costs and expenses after reimbursement limits are reached, including additional copayment and coinsurance amounts. Patients with high deductible or coinsurance health plans may pay more than $25. Patients in Massachusetts and Minnesota may pay as little as $35 copay. For questions, please call 1-877-494-4372.
• Savings may not be applied to any outstanding deductible or coinsurance a patient may have.
• VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024%, 90-day supply offer only applies if each of the three 2.5mL bottles is covered by the patient’s commercial insurance.
• This copay card is only valid for eligible patients with commercial insurance and not covered patients. “Not Covered Patients” are defined as those patients who have no health insurance or who have commercial insurance, but the drug is not covered on the plan’s formulary or has an NDC block, prior authorization, step edit or other restriction that has not been met.
• This copay card is not valid for any person who is 65 years of age or older without commercial insurance. You must be 18 years of age or older to redeem this copay card for yourself or a minor.
• This copay card 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 (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs.
• This copay card shall be applied only toward the cost of an eligible prescription product and not toward ancillary services or treatment costs.
• You agree not to seek reimbursement for all or any part of the benefit received through this copay card and are responsible for making any required reports of your use of this program to any insurer or other third party who pays any part of the prescription filled.
• This copay card is good only in the United States of America (including the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands) at retail pharmacies owned and operated by Walgreen Co. (or its affiliates) and other participating independent retail pharmacies.
• This copay card is not valid where prohibited, taxed, or otherwise restricted.
• This copay card is not valid for redemption in the States of California and Massachusetts or by any resident of the States of California or Massachusetts with regard to any product for which a therapeutically equivalent generic product is available including, but not limited to LOTEMAX® (loteprednol etabonate ophthalmic gel 0.5%), TIMOPTIC® in OCUDOSE® (timolol maleate ophthalmic solution) 0.5%, 0.3mL, and PROLENSA® (bromfenac ophthalmic solution) 0.07%.
• You must present this copay card along with your prescription to participate in this program.
• You must activate your copay card before use. Please activate online at bauschcopayprogram.com or on the phone by calling 1-877-494-4372.
• This copay card is good for use only with the products identified herein. No other purchase is necessary.
• This copay card cannot be redeemed at government-subsidized clinics.
• This copay card is not health insurance.
• The selling, purchasing, trading, or counterfeiting of this copay card is prohibited by law. Void if reproduced.
• This copay card is not valid with other offers. This copay card has no cash value. No cash back.
• Bausch + Lomb reserves the right to rescind, revoke, terminate, or amend this copay card at any time, without notice.
• When you use this copay card, you are certifying that you understand and agree to comply with the program rules, regulations, eligibility requirements, and terms and conditions.
• For questions call: 1-877-494-4372.