Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Updated December 17, 2014
 

Restasis

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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

  • Restasis Ophthalmic Emulsion 0.05% (cyclosporine ophthalmic)
 

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


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2. Updated October 17, 2014
 

Restasis

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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


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Restasis Ophthalmic Emulsion 0.05% (cyclosporine)
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 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 Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section and sign
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

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.