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 April 08, 2014
Botox

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


ALT PHONE: 800-44-BOTOX, opt 4
FAX: 877-530-6680
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Botox Patient Assistance Program

 

Medications

  • Botox Vial dosage varies (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 Mail or fax
Doctor's Action Complete section, 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

Contact program for Spanish application.



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 February 17, 2014
Botox

Botox Partnership for Access Prepaid MasterCard Program

This is a discount card program.

Provided by: Allergan, Inc.

PO Box 1370
San Bruno, CA 94066

TEL: 800-442-6869, opt 4


ALT PHONE: 800-44-BOTOX, opt 4
FAX:
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

 Botox Partnership for Access Prepaid MasterCard Program: Contact program

 

Medications

  • Botox Vial; Single-Use dosage varies (onabotulinumtoxinA)
 

Eligibility Requirements

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria FDA-approved diagnosis.
US Residency Required? Must reside in the US
   

Application

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
   

Medication

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 February 17, 2014
Botox

Botox Reimbursement Solutions

Pending.

Provided by: Allergan, Inc.

PO Box 1370
San Bruno, CA 94066

TEL: 800-442-6869, opt 4


ALT PHONE: 800-44-BOTOX, opt 4
FAX: 877-530-6680
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

 Botox Reimbursement Solutions: Contact program

 

Medications

  • Botox Vial; Single-Use dosage varies (onabotulinumtoxinA)
 

Eligibility Requirements

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

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
   

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.