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Allergan Patient Assistance Program: Medications/Devices

This is a copay assistance program

Provided by: Allergan, Inc.

PO Box 66764
St. Louis, MO 63166

TEL: 844-424-6727


ALT PHONE: 800-678-1605
FAX: 844-708-0036
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Allergan Patient Assistance Program Application: Medications/Devices

 

Brand Name Medications Covered

 
  • Aerochamber
  • Namenda oral solution
  • Aerochamber Plus Flow-Vu mouthpiece/mask
  • Namenda tablet
  • Armour Thyroid tablet
  • Namenda XR capsule; extended release-titration pack
  • Avycaz
  • Namzaric
  • Bystolic tablet
  • Pylera capsule
  • Byvalson
  • Rapaflo capsule
  • Canasa
  • Rectiv ointment
  • Crinone gel
  • Saphris tablet; sublingual
  • Dalvance
  • Savella tablet
  • Delzicol
  • Savella tablet; titration pack
  • Estrace cream; vaginal
  • Teflaro
  • Fetzima capsule; extended release
  • Trelstar
  • Fetzima Titration Pack capsule; extended release-titration pack
  • Viberzi
  • Gelnique gel; transdermal
  • Viibryd tablet
  • Infed injection
  • Viibryd tablet; titration pack
  • Liletta intrauterine device
  • Viokace tablet
  • Linzess
  • Vraylar
  • Monurol
  • Zenpep capsule; delayed release
 

Generic Name

 
  • asenapine maleate tablet; sublingual
  • memantine tablet
  • bismuth subcitrate-metronidazole/tetracycline capsule
  • memantine-donepezil
  • cariprazine
  • mesalamine
  • ceftaroline fosamil
  • milnaciprab tablet
  • ceftazidime/avibactam
  • milnaciprab tablet; titration pack
  • dalbavancin
  • nebivolol tablet
  • eluxadoline
  • nebivolol/valsartan
  • estradiol cream; vaginal
  • nitroglycerin ointment
  • fosfomycin tromethamine
  • oxybutynin chloride gel; transdermal
  • iron dextran injection
  • pancrelipase capsule; delayed release
  • levomilnacipran capsule; extended release
  • pancrelipase tablet
  • levomilnacipran capsule; extended release-titration pack
  • progesterone vaginal gel
  • levonorgestrel intrauterine device
  • silodosin capsule
  • linaclotide
  • thyroid desiccated tablet
  • medical device
  • triptorelin
  • medical device mouthpiece/mask
  • vilazodone tablet
  • memantine capsule; extended release-titration pack
  • vilazodone tablet; titration pack
  • memantine oral solution
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Yes, but have been denied or are ineligible for Low Income Subsidy
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be US citizen or legal entrant
   

Application

Obtaining Call or download
Receiving Mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Within 4 weeks
   

Medication

Amount/Supply 90 day supply with up to 3 refills, for a total of up to 1 year of medications
Sent To Doctor's office
Delivery Time Within 4 weeks
Refill Process New prescription every 3 months
Limit One year
Re-application New application every 12 months
   

Additional Information


Updated November 13, 2017