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

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: 800-553-6783

FAX: 513-618-0054
Languages Spoken:


Program Website


Patient Assistance Applications

Allergan Patient Assistance Program Application: Eye and Dermatology Medications


Brand Name Medications Covered

  • Acuvail ophthalmic solution
  • Restasis
  • Aczone gel
  • Restasis Multidose
  • Alphagan P ophthalmic solution
  • Rhofade
  • Combigan ophthalmic solution
  • Tazorac cream
  • Lumigan ophthalmic solution
  • Tazorac gel
  • Pred Forte ophthalmic suspension/drops

Generic Name

  • bimatoprost ophthalmic solution
  • ketorolac tromethamine ophthalmic solution
  • brimonidine tartrate ophthalmic solution
  • oxymetazoline
  • brimonidine tartrate/timolol maleate ophthalmic solution
  • prednisolone acetate ophthalmic suspension/drops
  • cyclosporine
  • tazarotene cream
  • dapsone gel
  • tazarotene gel

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 March 12, 2018