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This program provides brand name medications at no or low cost.
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| Pharmaceutical Company |
Allergan, Inc. |
| Program Name |
Allergan Patient Assistance Program |
| Program Address |
P.O. Box 6623
Somerset, NJ 08875 |
| Phone Number |
800-553-6783
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| Fax Number |
732-507-7636 |
| Medications on Program |
Sanctura XR Extended Release Tablets 60mg (trosplum choride)
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| Application Forms |
Allergan Patient Assistance Program
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On-line Application
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No on-line application available at this time |
| Web Site |
No link available. |
| Eligibility Guidelines and Notes |
The patient must have no prescription coverage for the requested medication and and have an income at or below 200% of the Federal Poverty Level, adjusted for family size. Medical diagnosis necessary for this program is not specified. The patient must live in the US and have a prescription from a doctor licensed in the US. Patients must provide their social security number.
Patients who are enrolled in Medicare Part D may still be enrolled in this program.
A maximum of two products may be requested in a six month period. Restasis may be requested every 3 months, and a 3 month supply sent. If more than 2 products are selected on one application, the application maybe be rejected.
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| Application Process |
The doctor or patient can call to request an application. The application can be either faxed or mailed out upon request. The completed application can be faxed or mailed back.
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| Application Requirements |
The doctor must fill out a section and sign the application. The patient must fill out a section, sign the application and attach proof of income.
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| Program Details |
A 6-month supply is sent to the doctor's office. A copy of the application signed by the doctor is needed for refills. Every year a new application is needed. Proof of income is required every 3 years.
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| Last Updated |
October 26, 2009 |
