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Program 1 of 2.
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Lumigan

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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:

English

Program Website

 

Program Applications and Forms

Allergan Patient Assistance Program Application: Eye and Dermatology Medications

 

Medications

  • Lumigan ophthalmic solution (bimatoprost)
 

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, and must be treated by US doctor
   

Application

Obtaining Call
Receiving Faxed or mailed
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 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

Proof of income is needed annually


Updated August 25, 2016


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

Lumigan

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Xubex Patient Assistance Program

This program provides medication at low cost. (Most brand names are provided for reference purposes only.)

Provided by: Xubex

PO Box 1244
Winter Park, Fl 32790-1244

TEL: 866-699-8239


ALT PHONE: 407-478-2663
FAX: 407-671-7960
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Xubex Patient Assistance Program Registration Form (pages 1 & 2)

Xubex Patient Assistance Program Physician Order Sheet (page 3)

 

Medications

  • Lumigan (bimatoprost)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes, but contact program for details
Income No limits
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Within 10 days
Refill Process Automatically sent out
Limit Varies per medication
Re-application New application, new documentation yearly
   

Additional Information

No proof of income is required. Check the website for the exact price.

This service is not currently available in Montana.


Updated August 05, 2016