Follow these simple steps to apply:

  • Get the application (click on the link after Step 4 below).
    • Complete the application online or print it and complete it by hand.
  • Complete the application.
    • To begin, read and follow all the instructions on the cover page
    • Complete the Patient Information and Insurance Information Sections on page 2
    • Print Your Application (6 Total Pages)
    • Read and sign the Patient Authorization and Certification on page 3
    • Attach a copy of your medical or prescription insurance cards
  • Bring the application to your prescriber.
    • Have your prescriber complete pages 4 through 6
    • Ensure Your Prescriber Completes the Prescription on Page 5, or provides a separate escript (if needed)
    • Ensure all Patient/Prescriber; Authorization, Consent, and Signature Sections are completed on Pages 3,5,6
    • Provide Copies of your Medical & Prescription Cards with your Application

    *IMPORTANT: If your application is incomplete for any reason, this could delay your acceptance into the program.

  • Submit the application.
    • Include the completed application form, documentation (if requested)
    • It would be helpful to also include a pharmacy printout of the patient Out-of-Pocket costs. These are the costs that the patient is responsible for when getting the prescription. Please ask your pharmacists to print a copy and attach it to the application.
    • It is not necessary to call for status updates. We will reach out to let you know the status of your application. Should you need to contact us, please keep a copy of your application and be prepared to provide the Application ID listed in the upper right hand corner of your application.

    • By mail

      Bausch Health Patient Assistance Program

      P.O. BOX 6122

      Lawrenceville, NJ 08648

      By fax


Next Steps

If you cannot print the application you can call us at 833-862-8727, 8 AM to 5 PM ET to have one mailed or emailed to you


We will review and confirm the information in your application and provide a response.


If approved, you are eligible to receive your Bausch Health prescription product(s) at no cost to you for up to one year.*

There is no maximum benefit limit. You may be able to reapply to the program annually if you continue to meet eligibility requirements and have a valid prescription.

*Patients with Medicare Part B or Medicare Part D who are found eligible will be approved through December 31.