Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated December 17, 2014
 

Lumigan

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Allergan Patient Assistance Program

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


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

English

Program Website

 

Patient Assistance Applications

Allergan Patient Assistance Program Application

 

Medications

  • Lumigan Ophthalmic Solution 0.01% (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
   

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