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Patient Assistance Information

 
3 Programs for ZYLET® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension)
 
 
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® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Valeant Patient Assistance Program

PO Box 429303
Cincinnati, OH 45242-9303
Phone : 1-833-862-VPAP (1-833-862-8727)
Fax: 1-866-777-5705
Eligibility
> The patient must be a legal US resident. The patient must be treated as outpatient and have a valid prescription from a licensed U.S. healthcare Professional for a product that is included in the Valeant PAP. The patient must be uninsured; be denied coverage for Valeant product by their commercial insurance provider and have exhausted all appeal options; or not have coverage for the Valeant 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). Income criteria varies by product. To determine your eligibility to apply, or to view our full Eligibility Requirements please visit our website at ValeantPAP.com.
Who Can Apply
> Patients in financial need who don’t have health insurance coverage for certain Valeant prescription products.
Required
> Complete the Patient Information and Insurance Information Sections on page 1.
Read and sign the Patient Authorization and Certification on page 2.
Have your prescriber complete pages 3 and 4 and sign Prescriber Certification on page 4.
Supply
> If applicable, attach a copy of your medical and prescription insurance cards.
Ship To
> Valeant prescription products are shipped to the Patient’s Home or Prescribing Physician’s Office. Orders for Controlled Substances and products administered by the physician will be shipped to comply with all state rules and regulations pertaining to how these items can be transported.
Note
> To determine your eligibility to apply, or to view our full Eligibility Requirements please visit our website at ValeantPAP.com. If you have questions about your eligibility or would like to speak with us about alternate funding options, please call the Valeant PAP at 833-862-VPAP (833-862-8727), 8 AM to 5 PM ET.
 
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® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application 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® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader