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Program 1 of 2.
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Vigamox

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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

  • Vigamox ophthalmic solution/drops (moxifloxacin)
 

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 April 26, 2016


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

Vigamox

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Xubex Patient Assistance Program

This program provides medication at low cost.

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

  • Vigamox ophthalmic solution/drops (moxifloxacin)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
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 May 18, 2016