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Patient Assistance Information

 
3 Programs for Zylet Ophthalmic Suspension
 
 
Bausch and Lomb Indigent Patient Program

1400 N Goodman St.
Rochester, NY 14609
Phone : 800-323-0000
Fax: Not Applicable
Eligibility
> 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.
Required
> 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.
Supply
>
Ship To
> Doctor's office
Note
> 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.
 
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
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US.
Who Can Apply
> Patients or healthcare providers can complete the application online or by phone.
Required
> Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
 
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.
 
Zylet Ophthalmic Suspension
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Xubex Pharmaceutical Services

PO Box 1244
Winter Park, FL 32790-1244
Phone : 866-699-8239
Fax: 407-671-7960
Eligibility
> Patients may have insurance. There are no income limits for this program. Patients must be a US resident.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application.
Supply
> Varies
Ship To
> Either Doctor's office or Patient's home
Note
> No proof of income is required. Check the website for the exact price. This service is not currently available in Montana.
 
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.
 
Zylet Ophthalmic Suspension
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader