Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 
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Allergan Patient Assistance Program: Eye and Dermatology Medications

This program provides brand name medications at no or low cost

Provided by: Allergan, Inc.


TEL: Closed Program


Languages Spoken:

English

 

Patient Assistance Applications

 

Generic Name

 
 

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 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 Within 4 weeks
   

Medication

Amount/Supply Up to 12 months
Sent To Doctor's office
Delivery Time Within 4 weeks
Refill Process Contact program for details.
Limit Not specified
Re-application New application every 12 months
   

Additional Information

Closed Program

Proof of income is needed annually


Updated October 12, 2018