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


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
  • Teflaro
  • Estrace cream; vaginal
  • Trelstar
  • Fetzima capsule; extended release
  • Viberzi
  • Fetzima Titration Pack capsule; extended release-titration pack
  • Viibryd tablet
  • Gelnique gel; transdermal
  • Viibryd tablet; titration pack
  • Infed injection
  • Viokace tablet
  • Liletta intrauterine device
  • Vraylar
  • Linzess
  • Zenpep capsule; delayed release
  • Monurol

Generic Name

  • asenapine maleate tablet; sublingual
  • memantine oral solution
  • bismuth subcitrate-metronidazole/tetracycline capsule
  • memantine tablet
  • cariprazine
  • memantine-donepezil
  • ceftaroline fosamil
  • mesalamine
  • ceftazidime/avibactam
  • milnacipran tablet
  • 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

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