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PROLENSA PART D COUPON PROGRAM

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Welcome

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.

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You must agree to each of the following statements to be eligible for the Part D Coupon Program:

ELIGIBILITY CRITERIA/TERMS AND CONDITIONS:

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