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

Program 1 of 3   Scroll down to see them all.  Updated March 12, 2013 Back | Print Page

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

Botox Patient Assistance Program

Provided by:


Allergan, Inc.
PO Box 1370
San Bruno, CA 94066

TEL: 800-44-BOTOX, opt 4


ALT PHONE: 800-442-6869, opt 4
FAX: 877-530-6680
 Program Website

Languages Spoken: English

Patient assistance
applications

 

Medications

Botox Injection  (onabotulinumtoxinA)

Eligibility Requirements

APPLICATION

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

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

Program 2 of 3   Scroll down to see them all.  Updated May 30, 2013 Back | Print Page

This is a discount card program.

Botox Partnership for Access Prepaid MasterCard Program

Provided by:


Allergan, Inc.
PO Box 1370
San Bruno, CA 94066

TEL: 800-44-BOTOX, opt 4


ALT PHONE: 800-442-6869 opt 4
FAX:
Program Website

Languages Spoken: English

Patient assistance
applications


 

Medications

Botox Injection  (onabotulinumtoxinA)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Can have insurance, but not Medicaid
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria FDA-approved diagnosis.
US Residency Required? Must reside in the US
Obtaining Enroll online
Receiving Not applicable
Returning Not applicable
Doctor's Action Give prescription to patient
Applicant's Action Complete online enrollment
Decision Communicated Not specified
Decision Timeframe Not specified
Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy or doctor's office
Delivery Time Not specified
Refill Process Good for one year
Limit One year
Re-application Patient contacts company

Additional Information:

Commercially insured patients meeting the eligibility with cervical dystonia or upper limb spasticity can receive up to $500 per treatment.
All other patients receiving BOTOX® for an FDA-approved indication can receive up to $100 per treatment.

The prepaid card is only good toward your out-of-pocket expenses for BOTOX® treatments
Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.

Program 3 of 3.  Updated May 30, 2013 Back | Print Page

Pending.

Botox Reimbursement Solutions

Provided by:


Allergan, Inc.
PO Box 1370
San Bruno, CA 94066

TEL: 800-44-BOTOX, opt 4


ALT PHONE: 800-442-6869 opt 4
FAX:
Program Website

Languages Spoken: English

Patient assistance
applications


 

Medications

Botox Injection  (onabotulinumtoxinA)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status
Those with Part D Eligible?
Income
Diagnosis/Medical Criteria
US Residency Required?
Obtaining Doctor/Doctor's office must call or download
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax 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
Amount/Supply
Sent To
Delivery Time
Refill Process
Limit
Re-application

Additional Information:

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



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