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

Allergan Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Allergan, Inc.

PO Box 66764
St. Louis, MO 63166

TEL: 844-424-6727


FAX: 844-708-0036
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Allergan Patient Assistance Program Application

 

Medications

  • asenapine maleate tablet; sublingual (Saphris) Tablet; Sublingual
 

Eligibility Requirements   

Insurance Status Contact program for details.
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 Faxed or downloaded from website
Returning Fax or mail from Doctor's office
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 5-7 business days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Doctor's office or pharmacy
Delivery Time Within 10 days
Refill Process Doctor/Doctor's office must contact the Program
Limit Varies
Re-application Those with Medicare Part D reapply Jan 1st, all others reapply on anniversary date of when they enrolled
   

Additional Information

Proof of income is needed annually

Letter of Medical Necessity must be included for Lexapro assistance


Updated September 28, 2020