Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Botox

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Botox Patient Assistance Program

This program provides brand name medications at no or low cost

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

 

Program Applications and Forms

Botox Patient Assistance Program Application

 

Medications

  • Botox vial (onabotulinumtoxinA)
 

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 November 08, 2016


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Botox

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Botox Reimbursement Solutions

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

 

Program Applications and Forms

 Botox Reimbursement Solutions: Contact program

 

Medications

  • Botox vial (onabotulinumtoxinA)
 

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 November 08, 2016