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Updated March 05, 2014
Alphagan P

Allergan Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Allergan, Inc.

P.O. Box 42847
Cincinnati, OH 45242

TEL: 800-553-6783


ALT PHONE:
FAX: 513-618-0054
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Allergan Patient Assistance Program

 

Medications

  • Alphagan P Ophthalmic Solution 0.1% (brimonidine tartrate)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income At or below 200% of FPL, adjusted for household size
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Doctor notified of denial
Decision Timeframe 2-4 business days
   

Medication

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