The LOTEMAX SM Part D Coupon Program is sponsored by Bausch + Lomb and designed to help reduce your out-of-pocket cost for LOTEMAX® SM if your Medicare Part D plan does not cover the product, or your out-of-pocket costs exceed $60* under that coverage, and you opt out of using your Medicare Part D prescription benefit in conjunction with this offer.

Please note that you have the option to use existing prescription coverage if you have it. If you elect to take advantage of this offer, you will need to opt out of using your Medicare Part D prescription benefit and agree to certain conditions.

To receive your LOTEMAX SM Part D coupon, please complete the requested information below.

*Terms, conditions and limitations apply. Most eligible patients pay no more than $60. See Eligibility Criteria/Terms and Conditions below.

* Required fields.

Please enter the date of birth of the patient who will use this coupon. *

! You must be 18 years of age or older to redeem this offer for yourself or a minor.

Please enter the 5-digit zip code of the residence of the patient who will use this coupon. *

! Please enter a valid 5-digit zip code.

Please enter the mobile phone number of the patient who will use this coupon. *

! Please enter a valid mobile number.

You must agree to each of the following statements to be eligible for the Part D Coupon Program:

I have Medicare Part D coverage or I am a Medicare Advantage patient. I do not have coverage through Medicaid, Tricare, DOD Tricare, VHA, IHS, SCHIP, or any other state or federal health programs. *

Agree

Disagree

I agree to not seek reimbursement from my Medicare or Medicare Advantage prescription plan for my out-of-pocket costs for LOTEMAX® SM purchased with the card. I will not count the cost of LOTEMAX® SM toward my deductible or true out-of-pocket cost. *

Agree

Disagree

I will purchase all of my prescriptions for LOTEMAX® SM before the end of the year using this card, and I will not use my Medicare Part D benefits for LOTEMAX® SM at any time during this calendar year, even if my benefits change. *

Agree

Disagree

I will notify my prescription plan that I have purchased LOTEMAX® SM outside my benefit by sending the form letter provided by Bausch + Lomb to the plan. *

Agree

Disagree

Please confirm that, by clicking submit to activate this coupon, you have read and understand the terms and conditions of the program, you currently meet all eligibility criteria and have read and agree with the Privacy Policy.*

Yes

ELIGIBILITY CRITERIA/TERMS AND CONDITIONS:

LOTEMAX SM Part D Coupon Program is valid for a cost reduction of a qualifying prescription of LOTEMAX® SM for eligible patients.
LOTEMAX SM Part D Coupon Program can only be used by eligible patients up to (6) times for LOTEMAX® SM.
You must have a prescription drug insurance through a Medicare Part D or a Medicare Advantage prescription drug plan.
You must agree to not seek reimbursement from your Medicare or Medicare Advantage prescription plan for your out-of-pocket costs for LOTEMAX® SM purchased with the card.
You must also agree not to count the cost of LOTEMAX® SM toward your deductible or true out-of-pocket cost.
You must notify your prescription plan that you have purchased LOTEMAX® SM outside of your benefit by sending the form letter provided by Bausch + Lomb at www.lotemaxsmpartdcoupon.com.
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.
LOTEMAX SM Part D Coupon Program card 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 offer.
LOTEMAX SM Part D Coupon Program card is not insurance.
LOTEMAX SM Part D Coupon Program card can be used at mail order pharmacies.
LOTEMAX SM Part D Coupon 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 LOTEMAX SM Part D Coupon Program card. Void if reproduced. Void where prohibited by law, taxed, or restricted.
Patients participating in Medicare Part D or a Medicare Advantage prescription drug plan who are eligible to use the LOTEMAX SM Part D Coupon Program card must agree to the following conditions: Patient must agree to not seek reimbursement from their Medicare or Medicare Advantage prescription plan for their out-of-pocket costs for LOTEMAX® SM purchased with the card.
Patient must also agree not to count the cost of LOTEMAX® SM toward their deductible or true out-of-pocket cost.
Patient must notify prescription plan that LOTEMAX® SM has been purchased outside of benefit by sending the form letter provided by Bausch + Lomb at www.lotemaxsmpartdcoupon.com.
The patient must purchase all prescriptions for LOTEMAX® SM before 12/31/19 with the card and the patient must not use Medicare Part D benefit for LOTEMAX® SM.
LOTEMAX SM Part D Coupon Program card 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.
This offer is not valid for redemption in the States of California and Massachusetts or by any resident of the States of California or Massachusetts with regard to any product for which a therapeutically equivalent generic product is available.
Bausch + Lomb reserves the right to rescind, revoke, or amend this offer at any time without notice.
Data related to your redemption of the LOTEMAX SM Part D Coupon Program card may be collected, analyzed, and shared with Bausch + Lomb, for market research and other purposes related to assessing patient savings programs. Data shared with Bausch + Lomb will be aggregated and de-identified, meaning it will be combined with data related to other card redemptions and will not identify the patient.
For questions call: 1-866-686-0130

LOTEMAX SM PART D COUPON PROGRAM

Welcome

You must agree to each of the following statements to be eligible for the Part D Coupon Program:

ELIGIBILITY CRITERIA/TERMS AND CONDITIONS: