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Program Details

BAUSCH HEALTH
Bausch Health Patient Assistance Program

Xifaxan (rifaximin)
 
CONTACT INFO
Address: PO Box 991624
Louisville, KY 40269
Phone: 1-833-862-8727 Provider Phone:
Fax: 1-844-705-0160 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be a legal United States resident.
  • Must have a valid prescription from a licensed U.S. healthcare professional for a product made available through the Bausch Health PAP.
  • Patient must not have insurance coverage for the prescribed Bausch Health product.
  • Eligibility for patients with Medicare Part D are determined on case-by-case basis.
  • Meet the pre-defined eligibility requirements and total annual household income requirements.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Varies
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Not Published
    Other Information:

    Last Updated: 03/15/2024

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)



     

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