Eligibility Criteria/Terms and Conditions: Part D Coupon Program is valid for a cost reduction of a qualifying prescription of LOTEMAX® SM, LOTEMAX® OINTMENT, LOTEMAX® GEL, PROLENSA® or ZYLET® for eligible patients. The card reduces an eligible patient’s out-of-pocket cost to as little as $80 per each prescription, even if the patient uses the card for more than one prescription. You must have prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan. Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the Part D Coupon Program card must agree to the following conditions: The patient must agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for the prescriptions purchased with the card. The patient must also agree not to count the cost of the prescriptions toward their deductible or true out-of-pocket cost. The patient must notify prescription plan that LOTEMAX® SM, LOTEMAX® OINTMENT, LOTEMAX® GEL, PROLENSA® or ZYLET® has been purchased outside of benefit by sending the form letter provided with this coupon. The patient is responsible for all additional costs and expenses after reimbursement limits are reached. The patient must purchase all prescriptions within the calendar year with the card and the patient must not use Medicare Part D benefit. Program is not valid for any patients with commercial/private insurance, uninsured patients, or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE. No other purchase necessary. Part D Coupon Program card is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer not already associated with this offer. Part D Coupon Program card is not insurance. Part D Coupon Program card can be used at mail order pharmacies. Part D Coupon Program card is the property of Bausch + Lomb and must be turned in on request. It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase, trade, or counterfeit the Part D Coupon Program card. Void if reproduced. Void where prohibited by law, taxed, or restricted. Part D Coupon Program card can be used only by eligible United States residents (including Puerto Rico, Guam and the US Virgin Islands) at participating eligible retail pharmacies in the United States. Product must originate from the United States. This offer 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® GEL (loteprednol etabonate ophthalmic solution) 0.5%. Bausch + Lomb reserves the right to rescind, revoke, or amend this offer at any time without notice. For questions call: 1-800-795-1091.
{"crx-wl-channel":"web","crx-wl-survey-description":"Agreement Certification","crx-wl-survey-name":"Bausch Lomb Part D Patient Survey v1.0.0","groupNumber":"AC68065007","brand":"bauschlombpartd","client":"valeant","brandPath":"bauschlombpartd","view":"print"}