| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 5. Scroll down to see them all. |
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restasis |
View Coupon |
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myAbbVie Assist for Eye CareThis program provides brand name medications at no or low cost |
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Provided by: AbbVie Inc. |
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PO Box 270 TEL: 800-222-6885FAX: 866-483-1305 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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myAbbVie Assist for Eye Care Application |
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myAbbVie Assist for Eye Care Application (Spanish) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must be uninsured or underinsured | ||
| Those with Part D Eligible? | Varies | ||
| Income | At or below 600% of FPL | ||
| Diagnosis/Medical Criteria | Not applicable | ||
| US Residency Required? | Must be a US resident and treated by a US licensed healthcare provider | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed 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 | Patient and Doctor are notified | ||
| Decision Timeframe | Not specified | ||
Medication |
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| Amount/Supply | As prescribed by Doctor | ||
| Sent To | Patient's home, unless otherwise noted | ||
| Delivery Time | Varies | ||
| Refill Process | Contact program for details. | ||
| Limit | Varies | ||
| Re-application | Varies | ||
Additional Information |
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| Any patient who requires the medication and are in need should call the company. Eligibility determined on a case-by-case basis. Patients with prescription drug coverage may be eligible on exception basis. Contact program for details. |
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| Updated May 22, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 5. Scroll down to see them all. |
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restasis |
View Coupon |
||
myAbbVie Assist Patient Assistance ProgramThis program provides brand name medications at no or low cost |
|||
Provided by: AbbVie Inc. |
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PO Box 270 TEL: 800-222-6885FAX: 866-483-1305 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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myAbbVie Assist Patient Assistance Program Application
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myAbbVie Assist Patient Assistance Program Application (Spanish)
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must be uninsured or underinsured | ||
| Those with Part D Eligible? | Varies | ||
| Income | At or below 600% of FPL | ||
| Diagnosis/Medical Criteria | Not applicable | ||
| US Residency Required? | Must be a US resident and treated by a US licensed healthcare provider | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed 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 | Patient and Doctor are notified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | As prescribed by Doctor | ||
| Sent To | Varies | ||
| Delivery Time | Varies | ||
| Refill Process | Contact program for details. | ||
| Limit | Varies | ||
| Re-application | Varies | ||
Additional Information |
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| Any patient who requires the medication and are in need should call the company. Eligibility determined on a case-by-case basis. Patients with prescription drug coverage may be eligible on exception basis. Contact program for details. |
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| Updated June 01, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 5. Scroll down to see them all. |
|||
restasis |
View Coupon |
||
myAbbVie Assist Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Allergan, Inc. |
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PO Box 270 TEL: 800-222-6885FAX: 866-483-1305 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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myAbbVie Assist Patient Assistance Program: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must be uninsured or underinsured | ||
| Those with Part D Eligible? | Varies | ||
| Income | At or below 600% of FPL | ||
| Diagnosis/Medical Criteria | Not applicable | ||
| US Residency Required? | Must be a US resident and treated by a US licensed healthcare provider | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed 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 | Patient and Doctor are notified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | As prescribed by Doctor | ||
| Sent To | Varies | ||
| Delivery Time | Varies | ||
| Refill Process | Contact program for details. | ||
| Limit | Varies | ||
| Re-application | Varies | ||
Additional Information |
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| Any patient who requires the medication and are in need should call the company. Eligibility determined on a case-by-case basis. Patients with prescription drug coverage may be eligible on exception basis. |
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| Updated June 01, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 4 of 5. Scroll down to see them all. |
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restasis |
View Coupon |
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Rx Outreach MedicationsThis program provides medication at low cost. (Most brand names are provided for reference purposes only) |
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Provided by: Rx Outreach |
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3171 Riverport Tech Center Dr. TEL: 314-222-0472ALT PHONE: 888-796-1234 FAX: 800-875-6591 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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Rx Outreach Application |
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Rx Outreach Application (Spanish) |
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Rx Outreach Refills Form |
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Rx Outreach Medication List (Alphabetized) |
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Rx Outreach Medication List (by Disease State) |
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Rx Outreach Medication List (by Disease State) (Spanish) |
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Rx Outreach Diabetic Supplies Order Form: Prodigy |
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Rx Outreach Diabetic Supplies Order Form: Prodigy (Spanish) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | May have insurance | ||
| Those with Part D Eligible? | Yes, but contact program for details | ||
| Income | Determined case by case | ||
| Diagnosis/Medical Criteria | Not required | ||
| US Residency Required? | Must reside in the US | ||
Application |
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| Obtaining | Call, download or apply online | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax | ||
| Doctor's Action | Give prescription to patient | ||
| Applicant's Action | Complete section and sign | ||
| Decision Communicated | Patient and/or Doctor are notified | ||
| Decision Timeframe | Usually same day | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Doctor's office or patient's home | ||
| Delivery Time | Not specified | ||
| Refill Process | Company contacts patient to arrange | ||
| Limit | Varies | ||
| Re-application | Not applicable | ||
Additional Information |
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| Rx Outreach has expanded the eligibility guidelines beyond 400% FPL to include people affected by COVID-19. Some medications are available for a fee of $20 for up to a 180 day supply. Check the Rx Outreach website for the exact price and most current medication list. Contact Program for Spanish Application(s)/Form(s). |
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| Updated May 23, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 5 of 5. | |||
restasis |
View Coupon |
||
Patient Access Network Foundation (PAN)This is a copay assistance program |
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Provided by: Patient Access Network Foundation |
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TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Patient Access Network Foundation (PAN) Application: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | *See Additional Information section below | ||
| Those with Part D Eligible? | Determined case by case | ||
| Income | Between 400-500% of FPL | ||
| Diagnosis/Medical Criteria | FDA Approved Diagnosis - See Program Website for Details | ||
| US Residency Required? | Must reside and receive treatment in US | ||
Application |
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| Obtaining | Call or complete online | ||
| Receiving | Complete online or by phone | ||
| Returning | Not applicable | ||
| Doctor's Action | Varies | ||
| Applicant's Action | Call for information or inform doctor that he/she is in need | ||
| Decision Communicated | Patient and Doctor are notified | ||
| Decision Timeframe | Within 48 hours | ||
Medication |
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| Amount/Supply | Not applicable | ||
| Sent To | Patient is sent savings card to be used at pharmacy | ||
| Delivery Time | Once approved; shipped same day | ||
| Refill Process | Patient presents voucher/card to pharmacy for each refill | ||
| Limit | None | ||
| Re-application | New application every 12 months | ||
Additional Information |
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| *Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
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| Updated May 30, 2023 | |||
