Welcome to the XIPERE Savings Program Eligible* commercially insured patients may pay as little as $0 out of pocket. *Enrollment period maximum benefit caps apply. Patients may pay out of pocket costs if enrollment period maximum benefit caps are met.
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Download Claim Submission Form Eligibility Criteria/Terms and Conditions: By using the XIPERE copay savings program, you confirm that you understand and agree to comply with the following terms and conditions of this offer:
This offer is valid for 12 months from the patient enrollment date. Reimbursement limitations apply. Patient is responsible for all additional costs and expenses after reimbursement limits are reached, including additional copayment and coinsurance amounts. This offer is only valid for eligible patients with commercial insurance and coverage. This offer is not valid for any person eligible for reimbursement of prescriptions, in whole or in part, by any federal, state, or other governmental programs, including, but not limited to, Medicare (including Medicare Advantage and Part A, B, and D plans), Medicaid, TRICARE, Veterans Administration or Department of Defense health coverage, CHAMPUS, the Puerto Rico Government Health Insurance Plan, or any other federal or state health care programs. This coupon shall be applied only toward the patient out of pocket cost for the product and not toward ancillary services or treatment costs. You agree not to seek reimbursement for all or any part of the benefit received through this offer and are responsible for making any required reports of your use of this offer to any insurer or other third party who pays any part of the prescription filled. This offer is good only in the United States of America (including the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands). This offer is not valid for any person who is 65 years of age or older without commercial insurance and coverage for the product. You must be 18 years of age or older to redeem this offer. This coupon is good for use only with the products identified herein. No other purchase is necessary. This offer is not valid where prohibited, taxed, or otherwise restricted. 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. This offer cannot be redeemed at government-subsidized clinics. This coupon and offer are not health insurance. The selling, purchasing, trading, or counterfeiting of this coupon is prohibited by law. Void if reproduced. This offer is not valid with other offers. This coupon has no cash value. No cash back. Bausch + Lomb reserves the right to rescind, revoke, terminate, or amend this offer at any time, without notice. This offer expires December 31, 2023. If you are not eligible for the XIPERE Savings Program, there may be other options for co-pay assistance.866-272-8838 to speak to a Focus on Access™ Representative or visit www.xipere.com
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CALIFORNIA RESIDENTS: DO NOT SELL MY PERSONAL INFORMATION
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