Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated September 11, 2014
 

Lotemax

Bausch and Lomb Indigent Patient Program

This program provides brand name medications at no or low cost.

Provided by: Bausch & Lomb Incorporated

US Patient Assistance Program
PO Box 2235
Morrisville, PA 19067-8035

TEL: 866-516-0744


ALT PHONE:
FAX: 800-233-9141
Languages Spoken:

English, Spanish

 

Patient Assistance Applications

Baush & Lomb Patient Assistance Program Application

 

Medications

  • Lotemax Gel 0.5% (loteprednol etabonate ophthalmic)
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income At or below $19,600 for an individual, $26,400 for a family
Diagnosis/Medical Criteria Not required
US Residency Required? No residency requirements
   

Application

Obtaining Doctor/Doctor's office must call
Receiving Faxed
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription and include copy of DEA or state license number
Applicant's Action Complete section and sign
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Up to 30 day supply
Sent To Doctor's office
Delivery Time Within 4-6 weeks
Refill Process New application and new prescription
Limit Not specified
Re-application New application needed for each fill
   

Additional Information

Contact program for Spanish application.