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Patient Assistance Information

Program Sponsored By Bausch & Lomb Incorporated (External Link)
Bausch and Lomb Indigent Patient Program

1400 N Goodman St.
Rochester, NY 14609
Phone : 800-323-0000
Fax: Not Applicable
> The patient must have no prescription coverage for the requested medication and have an income at or below $19,600 for an individual or $26,400 for a family.
Who Can Apply
> The doctor/doctor's office should call for an application.
> The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number.The patient must inform the doctor that s/he is in need.
Ship To
> Doctor's office
> The doctor/doctor's office should call for an application.
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
Alrex Suspension
Lotemax Suspension
OptiPranolol Solution
Zylet Ophthalmic Suspension
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form Application Form
(Requires Acrobat Reader