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Maxitrol

Alcon Cares

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

Provided by: ALCON Cares, Inc.

Alcon Cares, Inc.
TC39
6201 South Freeway
Fort Worth, TX 76134-0450

TEL: 800-222-8103


FAX: 800-554-2660
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Alcon Cares Application

 

Medications

  • Maxitrol ophthalmic ointment (dexamethasone/neomycin sulfate/polymyxin B sulfate)
  • Maxitrol ophthalmic suspension/drops (dexamethasone/neomycin sulfate/polymyxin B sulfate)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Considered on exception basis
Income At or below 200% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be treated by US Doctor
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income
Decision Communicated Patient notified of denial in writing
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Up to 6 months supply
Sent To Doctor's office
Delivery Time Within 3 weeks of receiving application
Refill Process Copy of application with new dates
Limit Not specified
Re-application New application yearly
   

Additional Information

Those over the 250% FPL guidelines may have their medical expenses taken into consideration. OTC products may be sent to either the patient's home or the doctor's office.

Some medications are available only as generic and some are available only as brand name.

CONTACT THE PROGRAM FOR DETAILS.

Contact program for Spanish application.


Updated July 13, 2016


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

Maxitrol

Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

 Patient Access Network Foundation (PAN) Application: Contact program

Patient Access Network Foundation (PAN) Provider Brochure

Patient Access Network Foundation (PAN) Patient Brochure

 

Medications

  • Maxitrol ophthalmic ointment (dexamethasone/neomycin sulfate/polymyxin B sulfate)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.




Updated June 15, 2016