ZELAPAR

Indicated For

Parkinson's disease

About This Medication

# Bausch Health Patient Assistance Program: How to Get ZELAPAR at Low or No Cost ## About This Program The Bausch Health Patient Assistance Program (BHC PAP) is designed to help uninsured and underinsured patients access prescription medications, including ZELAPAR (selegiline hydrochloride), at no cost or significantly reduced cost. This program provides eligible patients with up to 12 months of assistance from the date of approval, helping ensure that financial barriers do not prevent you from receiving the medication your doctor has prescribed. ## What is ZELAPAR? ZELAPAR is a prescription medication containing selegiline hydrochloride, used to treat symptoms of Parkinson's disease. Your healthcare provider has determined that this medication is appropriate for your medical condition. The Bausch Health Patient Assistance Program can help you access this medication if you meet the program's eligibility requirements. ## Who Qualifies for This Program? You may be eligible for the Bausch Health Patient Assistance Program if you meet all of the following criteria: - You are a legal United States resident - You have a valid prescription from a licensed U.S. healthcare professional for ZELAPAR - You are being treated as an outpatient (not hospitalized, in a nursing home, or in a correctional facility) - You do not have insurance coverage for ZELAPAR, or your insurance has denied coverage and you have exhausted all appeal options - Your total annual household income does not exceed 300% of the Federal Poverty Level (FPL) based on your household size - Your prescriber is not on the List of Excluded Individuals and Entities maintained by the Office of Inspector General ## Income Eligibility Requirements Your household income must not exceed 300% of the Federal Poverty Level. The Federal Poverty Level guidelines are updated annually and vary based on household size. To determine if you qualify, you will need to verify your household income against the current Federal Poverty Level Guidelines available at https://aspe.hhs.gov/poverty-guidelines. Income verification is required as part of the application process. You will need to provide documentation of your household income, such as recent tax returns, pay stubs, or other proof of income. ## Insurance Requirements The Bausch Health Patient Assistance Program is specifically designed for patients without adequate insurance coverage for ZELAPAR. Here's what this means: **You are eligible if you are:** - Completely uninsured, OR - Your commercial insurance has denied coverage for ZELAPAR and you have exhausted all appeal options, OR - You have government health insurance (Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE, or other federal/state pharmacy assistance programs) that does not cover ZELAPAR **Special note for Medicare Part D enrollees:** If you have Medicare Part D coverage, you may appeal for eligibility evaluation on a case-by-case basis. However, all Medicare Part D enrollees will be terminated from the program on December 31 and must reapply for the following year. **Special note for Medicaid patients:** If you are a Medicaid-only patient, you must download and complete the separate "Application for Medicaid-Only Patients" form available on the Bausch Health PAP website. Discount cards are not considered prescription drug coverage for program eligibility purposes. ## How to Apply: Step-by-Step Instructions **Step 1: Gather Required Documentation** Before starting your application, collect the following documents: - Your valid prescription for ZELAPAR from your healthcare provider - Front and back copies of your medical insurance card (if you have insurance) - Front and back copies of your prescription insurance card (if you have separate prescription coverage) - Proof of your household income (recent tax returns, pay stubs, or other income documentation) - A pharmacy statement (if available) **Step 2: Complete the Patient Information Section** Download the application form from BauschHealthPAP.com. Fill out the Patient Information section on page 2, including your name, address, contact information, and household size. **Step 3: Complete the Insurance Information Section** Provide details about your current health insurance and prescription drug coverage on page 2. If you are uninsured, indicate this clearly. **Step 4: Read and Sign the Patient Authorization** Carefully read the Patient Authorization and Certification on page 3. This form authorizes Bausch Health to verify your eligibility and process your application. Sign and date this section. **Step 5: Have Your Prescriber Complete Their Section** Give your healthcare provider pages 4, 5, and 6 of the application. Your prescriber must: - Confirm that ZELAPAR is medically necessary for your condition - Verify that you are being treated as an outpatient - Complete the Prescriber Certification on page 6 - Sign the form with a DocuSign signature or original signature (stamped signatures are not allowed for controlled substances) **Step 6: Attach Supporting Documents** Make copies of: - Front and back of your medical insurance card - Front and back of your prescription insurance card - Any pharmacy statements - Your proof of income documentation Attach these copies to your completed application. **Step 7: Submit Your Application** Submit your completed application and all supporting documents by fax or mail: **Fax:** 844-705-0160 **Mail:** BAUSCH HEALTH PATIENT ASSISTANCE PROGRAM, P.O. Box 991624, Louisville, KY 40269 **Important:** If any required information (marked with an asterisk on the form) is missing, your application will be put on hold until all missing information is received. ## Application Timeline and Delivery All applications are reviewed on a case-by-case basis. While specific processing times are not publicly stated, you should expect to wait several weeks for a decision. Once approved, your ZELAPAR will be shipped directly to you at no cost. Your approval is valid for up to 12 months from the date of approval. If you are a Medicare Part D enrollee, you will be terminated on December 31 and must reapply for continued coverage in the following year. ## What Happens If Your Application is Denied? If your application is denied, you have several options: 1. **Review the denial reason:** Contact Bausch Health at 833-862-8727 (8 AM to 5 PM ET) to understand why your application was not approved. 2. **Verify your eligibility:** Double-check that you meet all requirements, particularly income and insurance criteria. 3. **Reapply:** If your circumstances have changed (such as a change in income or insurance status), you may reapply to the program. 4. **Explore other assistance options:** Ask your healthcare provider or pharmacist about other patient assistance programs, community health centers, or pharmaceutical discount programs that may help you access ZELAPAR. 5. **Contact your state pharmacy assistance program:** Many states offer additional prescription assistance programs that may be able to help. ## Reauthorization and Continued Eligibility The Bausch Health Patient Assistance Program will reconfirm your continued income and insurance eligibility annually. If your circumstances change—such as a change in insurance status or household income—you may be deemed no longer eligible for the program. If you are approved, you are eligible to receive assistance for up to 12 months from your approval date. Before your 12-month period ends, you may reapply to the program if you continue to meet all eligibility requirements and have a valid prescription from your healthcare provider. ## Important Disclaimer This guide provides general information about the Bausch Health Patient Assistance Program. Program requirements, eligibility criteria, and benefits may change. For the most current and complete information, visit BauschHealthPAP.com or call 833-862-8727. All applications are reviewed on a case-by-case basis, and Bausch Health Companies Inc. reserves the right to determine your participation in the program. This program is subject to all applicable federal, state, and local laws and regulations.

Program information last verified: March 30, 2026