To receive any of the products listed in the adjacent table, patient enrollment is needed.

Online enrollment is quickest. Click the Enroll Here button and follow the prompts Mail or fax is also available.

[Click here] to download the enrollment form. Mail and fax information is on the form.

Questions: 844-813-3864

(Monday – Friday, 8 am – 10 pm ET)

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30-Day Supply
90-Day Supply
Zioptan
$60

1 carton of 30 single use containers

$150

3 cartons of 30 single use containers

Betimol
$60

1 - 5 mL bottle

$150

3 - 5 mL bottle

Zioptan
$60

1 carton of 60 single use containers

$150

3 cartons of 60 single use containers

AzaSile
$60

1 - 5 mL bottle