BIN#: 019158 PCN#: CNRX GRP#: AC68050003
ACCESS PROGRAM COUPON
ACCESS PROGRAM
EXCLUSIVELY AT WALGREENS AND OTHER
PARTICIPATING INDEPENDENT PHARMACIES
Help Line: 1-866-693-4880
Eligibility Criteria/Terms and Conditions:
By using the Bausch + Lomb Access coupon, you confirm that you understand and agree
to comply with the following terms and conditions of this offer:
• This coupon is valid for (6) fills per product per patient in a 12-month period.
• Reimbursement limitations apply. Patient is responsible for all additional costs and
expenses after reimbursement limits are reached. For questions, please
call 1-866-693-4880.
• This offer is only valid for eligible patients with commercial insurance and eligible
uninsured patients. “Eligible Uninsured Patients” are defined as those patients who
have no health insurance or who have commercial insurance, but the drug is not
covered on the plan’s formulary or has an NDC block, prior authorization, step edit or
other restriction that has not been met.
• 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 cost of an eligible prescription 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) at retail pharmacies owned
and operated by Walgreen Co. (or its affiliates) and other participating independent
retail pharmacies.
• This offer is not valid in Massachusetts or Minnesota or where otherwise 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 including, but not limited
to, ISTALOL® (timolol maleate ophthalmic solution) 0.5% and LOTEMAX® (loteprednol
etabonate ophthalmic suspension) 0.5%.
• This offer is not valid for any person that is 65 years of age or older without
commercial insurance. You must be 18 years of age or older to redeem this offer for
yourself or a minor.
• For a 1-month supply, Eligible Uninsured Patients may pay no more than $75. For
larger bottle sizes, Eligible Uninsured Patients may pay no more than:
» $115 for ALREX® (loteprednol etabonate ophthalmic suspension) 0.2%, BEPREVE®
(bepotastine besilate ophthalmic solution) 1.5%, and ZYLET® (loteprednol etabonate
0.5% and tobramycin 0.3% ophthalmic suspension) (10mL)
» $120 for VYZULTA® (latanoprostene bunod ophthalmic solution), 0.024% (5mL)
• For ZIRGAN® (ganciclovir ophthalmic gel) 0.15%, Eligible Uninsured Patients save up to
$135 for a 5 g tube.
• You must present this coupon along with your prescription to participate
in this program.
• You must activate your coupon before use. Please activate online at
www.blsavings.com, on the phone by calling 1-866-693-4880, or by texting BLSAVINGS
to 24109 to activate. Message and data rates may apply. The full terms can be viewed at
https://bauschaccess.copaysavingsprogram.com/sms-terms.
®/TM are trademarks of Bausch & Lomb Incorporated or its affiliates except Zirgan is a
registered trademark of Laboratoires Théa Corporation used under license.
Any product/brand names and/or logos are trademarks of the respective owners.
©2019 Bausch & Lomb Incorporated or its affiliates. ALX.0103.USA.19
ID#: 19297278798
• This coupon is good for use only with the products identified herein. No other purchase
is necessary.
• 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.
• When you use this coupon, you are certifying that you understand and agree to comply
with the program rules, regulations, eligibility requirements, and terms and conditions.
• For questions call: 1-866-693-4880.
• This offer expires December 31, 2020.
To the Pharmacist: 
• For eligible commercially insured patients: Submit claim to the primary Third Party
Payer first, then submit the balance due to SS&C Health as a Secondary Payer as a
copay only. Bill using BIN 019158 and a valid Other Coverage
Code (e.g. 08).
• For eligible patients who are commercially insured but product is not covered: Submit
claim using BIN 019158 and a valid Other Coverage Code (e.g. 03).
• For eligible patients who do not have health insurance: Submit claim using BIN 019158
and a valid Other Coverage Code (e.g. 01).
• Reimbursement will be received from SS&C Health. For questions regarding SS&C
Health’s online processing, please call the Help Desk at 1-844-373-0987.
• Third-Party Discount Cards and other non-insurance plans are not valid as primary
payers under this offer. This offer cannot be combined with any other rebate/coupon,
free trial or similar offer for the specified prescription.
• When you use this coupon you are certifying that you have not submitted and will not
submit a claim for reimbursement under 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 offer is not valid for any
person eligible for reimbursement of prescriptions, in whole or in part by any of these
programs.
• By accepting this coupon and submitting claims for any of the products specified
herein you agree to the program terms and conditions, which are posted at www.
bauschaccessprogram.com.
• Bausch + Lomb reserves the right to rescind, revoke, or change this offer at any time.
• This offer is only valid for eligible patients with commercial insurance and Eligible
Uninsured Patients.
• This offer is not valid for any person that is 65 years of age or older without
commercial insurance. Participants must be 18 years of age or older to
redeem this offer for him/herself or a minor.
• For questions call: 1-866-693-4880.
• This offer expires December 31, 2020.