PART D OPT-OUT CASH PURCHASE PROGRAM

Eligibility Criteria/Terms and Conditions

The Part D Opt-Out Cash Purchase Program is valid for a cost reduction of a qualifying prescription of LOTEMAX^® SM (loteprednol etabonate ophthalmic gel) 0.38%, LOTEMAX^® Ointment (loteprednol etabonate ophthalmic ointment) 0.5%, LOTEMAX^® Gel (loteprednol etabonate ophthalmic gel) 0.5%, PROLENSA^® (bromfenac ophthalmic solution) 0.07%, VYZULTA^® (latanoprostene bunod ophthalmic solution), 0.024%, ZYLET^® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension), or ZIRGAN^® (ganciclovir ophthalmic gel) 0.15% for eligible patients.

• The Part D Opt-Out Cash Purchase Program reduces most eligible patients' out-of-pocket cost to as little as $79 per each prescription, or $47 per month for each 90-day VYZULTA^® prescription, even if the patient uses the program for more than one prescription.
• The Part D Opt-Out Cash Purchase Program reduced cost available for cash-paying patients only. Eligible VYZULTA^® patients pay $79 for a 30-day supply, $109 for a 60-day supply, and $139 for a 90-day supply of VYZULTA^® per prescription, including refills.
• You must have prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
• Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the Part D Opt-Out Cash Purchase Program must agree to the following conditions:
  • The patient must agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for the prescriptions purchased with the Part D Opt-Out Cash Purchase Program.
  • The patient must also agree not to count the cost of the prescriptions toward their deductible or true out-of-pocket cost.
  • The patient must notify prescription plan that LOTEMAX^® SM, LOTEMAX^® Ointment, LOTEMAX^® Gel, PROLENSA^®, VYZULTA^®, ZYLET^®, or ZIRGAN^® has been purchased outside of benefit by sending the form letter provided with this card.
  • The patient is responsible for all additional costs and expenses after reimbursement limits are reached.
  • The patient must purchase all prescriptions with the Part D Opt-Out Cash Purchase Program and the patient must not use Medicare Part D benefit.
• The Part D Opt-Out Cash Purchase Program is not valid for any patients with commercial/private insurance, uninsured patients, or patients with prescription coverage under any other federal or state health program such as Medicaid or TRICARE.
• No other purchase necessary.
• The Part D Opt-Out Cash Purchase Program is not transferable. No substitutions are permitted. Cannot be combined with any other coupon, free trial, discount, prescription savings card, or other offer not already associated with this program.
• The Part D Opt-Out Cash Purchase Program is not insurance.
• The Part D Opt-Out Cash Purchase Program can be used at mail order pharmacies.
• The Part D Opt-Out Cash Purchase Program card is the property of Bausch + Lomb and must be turned in on request.
• It is illegal to sell, purchase, trade, or counterfeit, or offer to sell, purchase trade, or counterfeit the Part D Opt-Out Cash Purchase Program card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
• The Part D Opt-Out Cash Purchase Program can be used only by eligible United States residents (including Puerto Rico, Guam and the US Virgin Islands) at participating eligible retail pharmacies in the United States. Product must originate from the United States.
• The Part D Opt-Out Cash Purchase Program is not valid for redemption in the State of Massachusetts or by any resident of the State of Massachusetts with regard to any product for which a therapeutically equivalent generic product is available including, but not limited to, LOTEMAX^® Gel and PROLENSA^®.
• Bausch + Lomb reserves the right to rescind, revoke, or amend the Part D Opt-Out Cash Purchase Program at any time without notice.
• For questions call: 1-800-795-1091.