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Patient Assistance Information

 
 
 
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.
 
ACANYA® (clindamycin phosphate and benzoyl peroxide) Gel
ALREX® (loteprednol etabonate ophthalmic suspension)
ANCOBON® (flucytosine) Capsules
ANDROID® (C-III) (methylTESTOSTERone Capsules, USP)
APRISO® (mesalamine) extended-release capsules
BEPREVE® (bepotastine besilate ophthalmic solution)
BESIVANCE® (besifloxacin ophthalmic suspension)
CARAC® (fluorouracil cream) Cream
CLINDAGEL® (clindamycin phosphate gel) topical gel
CUPRIMINE® (penicillamine) Capsules
CYCLOSET® (bromocriptine mesylate tablets)
DEMSER® (metyrosine) Capsules
ELIDEL® (pimecrolimus) Cream
JUBLIA® (efinaconazole) topical solution
LACRISERT® (hydroxypropyl cellulose ophthalmic insert)
LOCOID® (hydrocortisone butyrate) Lotion
LODOSYN® (carbidopa) tablets
LOTEMAX® (loteprednol etabonate ophthalmic gel)
LUZU® (luliconazole) Cream
MACUGEN® (pegaptanib sodium injection) intravitreal injection
MEPHYTON® (phytonadione) Vitamin K1 tablets
MOVIPREP® (polyethylene glycol 3350, sodium sulfate, sodium chloride, potassium chloride, sodium ascorbate, and ascorbic acid for oral solution)
NORITATE® (metronidazole cream) Cream
ONEXTON® (clindamycin phosphate and benzoyl peroxide) Gel
OXSORALEN-ULTRA® Capsules (methoxsalen capsules, USP, 10 mg)
PROLENSA® (bromfenac ophthalmic solution)
RELISTOR® (methylnaltrexone bromide) injection
RELISTOR® (methylnaltrexone bromide) tablets
RENOVA® (tretinoin cream)
RETIN-A MICRO® (tretinoin) Gel
RETISERT® (fluocinolone acetonide intravitreal implant)
SOLODYN® (minocycline HCI) extended release tablets
SYPRINE® (trientine hydrochloride) capsules
TARGRETIN® (bexarotene) capsules
TARGRETIN® (bexarotene) Gel
TASMAR® (tolcapone) Tablets
TIMOPTIC® in OCUDOSE® (timolol maleate ophthalmic solution)
UCERIS® (budesonide) Extended Release Tablets
UCERIS® (budesonide) rectal foam
VISUDYNE® (verteporfin for injection)
VYZULTA™ (latanoprostene bunod ophthalmic solution)
XIFAXAN® (rifaximin) Tablets
ZELAPAR® (selegiline hydrochloride) Orally Disintegrating Tablets
ZIRGAN® (ganiciclovir ophthalmic gel)
ZYCLARA® (imiquimod) cream
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