The PROLENSA Part D Coupon Program is sponsored by Bausch + Lomb and designed to reduce your out-of-pocket cost for PROLENSA® if your Medicare Part D plan does not cover the product, or your out-of-pocket costs exceed $60*, and you opt out of using your Medicare Part D prescription benefit in conjunction with this offer.
Please note that you have the option to use existing prescription coverage if you have it. If you elect to take advantage of this offer, you will need to opt out of using your Medicare Part D prescription benefit and agree to certain conditions.
To receive your PROLENSA Part D coupon, please complete the requested information below.
*Terms and conditions apply. Most eligible patients pay no more than $60. See Eligibility Criteria/Terms and Conditions below.
* Required fields.
ELIGIBILITY CRITERIA/TERMS AND CONDITIONS:
PROLENSA Part D Coupon Program card is valid for a cost reduction of a qualifying prescription of PROLENSA® for eligible patients.
PROLENSA Part D Coupon Program card can only be used by eligible patients up to (6) times for PROLENSA®.
Maximum Bausch + Lomb contribution is $220 per prescription.
You must have a prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
You must agree to not seek reimbursement from your Medicare or Medicare Advantage prescription plan for your out-of-pocket costs for PROLENSA® purchased with the card.
You must also agree not to count the cost of PROLENSA® toward your deductible or true out-of-pocket cost.
You must notify your prescription plan that you have purchased PROLENSA® outside of your benefit by sending the form letter provided by Bausch + Lomb at www.prolensapartdcoupon.com.
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.
PROLENSA 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.
PROLENSA Part D Coupon Program card is not insurance.
PROLENSA Part D Coupon Program card can be used at mail order pharmacies.
Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the PROLENSA Part D Coupon Program card must agree to the following conditions: Patient must agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for PROLENSA® purchased with the card.
Patient must also agree not to count the cost of PROLENSA® toward their deductible or true out-of-pocket cost.
Patient must notify prescription plan that PROLENSA® has been purchased outside benefit by sending the form letter provided by Bausch + Lomb at www.prolensapartdcoupon.com.
The patient must purchase all prescriptions for PROLENSA® before 12/31/19 with the card and the patient must not use Medicare Part D benefit for PROLENSA®.
PROLENSA 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.
PROLENSA 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 PROLENSA Part D Coupon Program card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
Bausch + Lomb reserves the right to rescind, revoke, or amend this offer at any time without notice.
Data related to your redemption of the PROLENSA Part D Coupon Program card may be collected, analyzed, and shared with Bausch + Lomb, for market research and other purposes related to assessing patient savings programs. Data shared with Bausch + Lomb will be aggregated and de-identified, meaning it will be combined with data related to other card redemptions and will not identify the patient.