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

Botox Reimbursement Solutions (BRS)

For Healthcare Professionals Only

Provided by: Allergan, Inc.

PO Box 1370
San Bruno, CA 94066

TEL: 800-442-6869, opt. 4


FAX: 877-530-6680
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Botox Reimbursement Solutions: Contact program

 

Brand Name Medications Covered

 
  • Botox vial
 

Generic Name

 
  • onabotulinumtoxinA vial
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Not specified
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be residing in the US or Puerto Rico
   

Application

Obtaining Doctor/Doctor's office must call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail from Doctor's office
Doctor's Action Register with program, complete sections, obtain patients completed application with income documentation
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Doctor notified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Resources for HEALTHCARE PROFESSIONAL ONLY.
The Doctor must contact the program to place an order.


Updated July 07, 2017