Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

Botox Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Allergan, Inc.

PO Box 220350
Charlotte, NC 28222-0350

TEL: 800-442-6869, opt. 4


FAX: 866-217-7178
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Botox Patient Assistance Program Application

 

Brand Name Medications Covered

 
  • Botox vial
 

Generic Name

 
  • onabotulinumtoxinA vial
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? No
Income At or below 300% of FPL
Diagnosis/Medical Criteria Diagnosis must be supported in Comendia
US Residency Required? Must reside permanently in the US or Puerto Rico
   

Application

Obtaining Call or download
Receiving Mailed to doctor, patient or social worker
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Not specified
Sent To Doctor's office
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information


Updated September 08, 2017