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Allergan Patient Assistance Program: Eye and Dermatology Medications

This program provides brand name medications at no or low cost

Provided by: Allergan, Inc.

PO Box 42847
Cincinnati, OH 45242

TEL: 844-424-6727

ALT PHONE: 800-553-6783
FAX: 513-618-0054
Languages Spoken:


Program Website


Program Applications and Forms

Allergan Patient Assistance Program Application: Eye and Dermatology Medications



  • Aczone gel (dapsone)

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income At or below 400% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes, and must be treated by US doctor


Obtaining Call
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Doctor notified of denial
Decision Timeframe 2-4 business days


Amount/Supply Up to 6 months supply
Sent To Doctor's office
Delivery Time Not specified
Refill Process Copy of application with new doctor signature
Limit Not specified
Re-application New application every 12 months

Additional Information

Proof of income is needed annually

Updated July 16, 2018