Help Your Patients access Their Bausch Health medications

The Bausch Health Patient Assistance Program can help your eligible patients with no or limited insurance and/or qualifying financial need access their medication for free.

How the Bausch Health Patient Assistance Program Works

In 3 simple steps, your patients can apply to receive free medication.

1 Check eligibility

Review the program eligibility criteria and list of, eligible medications to confirm if your patient may qualify.

2 Submit application

Complete the application form with the patient (they may also complete it on their own). Your signature is required to verify the prescription. 

3 Patient receives medication

If approved, free medication will be shipped directly to your patient’s home. No co-pays or shipping fees.

You can receive medication Coverage lasts up to 1 year and patients can re-apply annually.

Download Program Application Forms

Select the right form based on your patient’s insurance type:

Patients on Medicaid

Patients with Medicaid who no longer have their Bausch Health medication covered may be eligible to receive it for free.

Download Medicaid patients form Download Medicaid patients form

Patients not on Medicaid who are uninsured/underinsured

Patients not on Medicaid and who do not have coverage for their Bausch Health medication and/or who demonstrate qualifying financial need may be eligible to receive it for free.

Download Non-Medicaid patients form Download non-Medicaid patients form

3 Ways to Submit Your Patient’s Application

Phone Phone

Apply on behalf of your
patients by calling
1-833-862-8727

alert Only patients on Medicaid can be enrolled over the phone. For all other patients, please apply by mail or fax. 

Mail Mail

Send the completed application
form to:
Bausch Health
Patient Assistance Program
P.O. Box 991624
Louisville, KY 40269

Fax Fax

Fax the completed application
form to
1-844-705-0160

The following information is required to complete the application.

Please take a moment to review this with your patient to ensure their application is not rejected for being incomplete. All personal information is kept secure and confidential.

Patient information

  • Name, date of birth, contact information
  • Social Security Number
  • Insurance status/coverage (if any)
  • Annual household income (Medicaid applicants)
  • Proof of out-of-pocket cost (non-Medicaid applicants)

Prescription Details

  • Medication name, format and dosage
  • Valid prescription with your signature
  • Your NPI number and contact information

Have Questions or Need Support?

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