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Click ‘Get Form’ to open the Bausch Patient Assistance Program Application PDF in the editor.
Begin by filling out the Patient Information section on page 2. Ensure all fields marked with an asterisk (*) are completed, including your name, address, and contact information.
Next, complete the Insurance Information section. If you do not have insurance, check the appropriate box and proceed to page 3.
On page 3, read and sign the Patient Authorization and Certification. This step is crucial for allowing Bausch Health to process your application.
Have your prescriber fill out pages 4 through 6. They must provide their certification and prescription details for the requested product.
Finally, attach copies of your medical and prescription insurance cards as required. Ensure that all necessary documents are included before submission.

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What is Bausch Health patient Assistance Program?

The purpose of the Bausch Health Patient Assistance Program is to help those eligible patients who are prescribed certain Bausch Health Companies, Inc products obtain those products although financial circumstances or insurance status may otherwise interfere with the ability to do so.

How do I apply for Xiidra patient assistance program?

Pharmaceutical manufacturers may sponsor patient assistance programs (PAPs) that provide financial assistance or drug free product (through in-kind product donations) to low income individuals to augment any existing prescription drug coverage.

Who funds patient assistance programs?

This program provides brand name medications at no or low cost for patients that have no prescription coverage. Patients must be at or below 200% of the federal poverty level. The medication must be deemed medically necessary by a doctor and patients must be a US citizen or legal resident.

How does Novartis patient assistance work?

Novartis Patient Assistance Foundation, Inc. (NPAF), an independent 501(c)(3) non-profit organization, provides Novartis medications free of cost to eligible patients who have limited or no prescription insurance coverage and cannot afford the cost of their medication.

What is proof of income for Novartis patient assistance?

Please note, you will need to submit the first two pages of your household tax return to confirm your income.

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