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

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:


Program Website


Program Applications and Forms

Allergan Patient Assistance Program Application: Medications/Devices



  • Avycaz (ceftazidime/avibactam)

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


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


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 August 09, 2018