Hardship appeals for patients residing in Puerto Rico will be reviewed by the Bausch + Lomb Patient Assistance Program on a case-by-case basis.
You are being treated as an outpatient and have a valid prescription from a licensed U.S. healthcare professional for a product that is included in the Bausch + Lomb Patient Assistance Program.
You do not reside in a hospital, nursing home, correctional facility or court-appointed program or facility.
In terms of health insurance, you must:
be denied coverage for Bausch + Lomb product by your commercial insurance provider and have exhausted all appeal options; or,
not have coverage for the Bausch + Lomb product requested through government health insurance, (i.e., Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE or other federal or state pharmacy assistance programs).
If you have coverage for the Bausch + Lomb product requested through Medicare Part B or Medicare Part D, you may appeal for evaluation of eligibility. Appeals will be reviewed on a case-by-case basis.
Discount cards are not considered prescription drug coverage for purposes of program eligibility.
Your annual household income must not exceed 300% of the Federal Poverty Level (“FPL”) based on household size (Federal Poverty Level Guidelines available at https://aspe.hhs.gov/poverty-guidelines).
For valid prescriptions for RETISERT®, or VISUDYNE®, or XIPERE™ your annual household income must not exceed $100,000.
NOTE: Child support, food stamps, and/or alimony are not included in your income calculation.
You may be asked to submit documentation (e.g., federal tax returns; IRS forms such as W-2, 1099, 4506T; Social Security statement/checks/beneﬁt letter; pension or disability beneﬁt statement/letter; unemployment compensation statement; pay stubs) to validate levels of income.
If you have no income, your prescriber or patient advocate must sign a letter attesting to that.
You and your prescriber may not bill, charge, seek credit for or otherwise submit any claim for reimbursement to any third party payer for product provided through the Bausch + Lomb Patient Assistance Program.
No product provided through the Bausch + Lomb Patient Assistance Program may be sold, traded, or returned for credit.
Bausch + Lomb Companies, Inc., has the right to verify your eligibility, including the right to audit any information provided on the Bausch + Lomb Patient Assistance Program application form.
Your prescriber must not be on the List of Excluded Individuals and Entities maintained by the Office of Inspector General, U.S. Department of Health and Human Services, or prohibited from participating in federally funded health care programs.
Bausch + Lomb Companies, Inc., in its sole discretion can determine your participation in the Bausch + Lomb Patient Assistance Program.
Approved patients are eligible to receive assistance for up to 12 months from the date of approval.
Bausch + Lomb Patient Assistance Program will reconﬁrm continued income and insurance eligibility annually. If you have a change in insurance status or income, you may be deemed no longer eligible for the program.
If you were previously denied enrollment in the Bausch + Lomb Patient Assistance Program, you may reapply if you experience a change in circumstance impacting your eligibility.
The program requires that you re-enroll every year by completing a Bausch + Lomb Patient Assistance Program application form. A notice regarding re-enrollment will be sent to you 60 days prior to the anniversary date of your participation in the program or, in some cases, by December 31.
Bausch + Lomb Patient Assistance Program beneﬁts, rules, and product availability are subject to change at any time without prior notiﬁcation.