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Allergan Patient Assistance Program

Summary

Allergan, Inc. was founded in Irvine, California in 1948. They are a worldwide provider of pharmaceutical and medical device products revolving around the ophthalmic, neurological, medical aesthetics, medical dermatological, breast aesthetics, and obesity intervention markets. Allergan, Inc. produces both prescription and non-prescription products for treatment of: glaucoma, ocular inflammation, bacterial conjunctivitis, infection allergy, dry eye disease, acne, wrinkles, psoriasis, rosacea, and neuromuscular disorders.

The medications listed to the right include Allergan, Inc.'s treatments for dry eye disease, glaucoma, and psoriasis.

Eligibility

Allergan Patient Assistance Program is the core patient assistance program provided by Allergan, Inc.. They offer all of the medications listed to the right at no cost for a 6 month supply to those who are eligible for the program. Eligibility is based off of the following requirements:

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You must not be covered by any private or public prescription coverage programs.

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You must be a citizen of the United States or its Territories.

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You may select no more than two products in a 6 month period.

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Your income must be less than or equal to 165% of the Federal Poverty Guideline for the size of your household (see chart below).

Note: Having Medicare Part D or a high co-pay does not exclude you from eligibility and it is recommended that you still apply.

The medication must be sent to the physicians office.

SOURCE: 2008 Poverty Chart

Family Size	100%	133%	150%	200%	250%	300%
1	$10,830	$14,404	$16,245	$21,660	$27,075	$32,490
2	$14,570	$19,378	$21,855	$29,140	$36,425	$43,710
3	$18,310	$24,352	$27,465	$36,620	$45,775	$54,930
4	$22,050	$29,327	$33,075	$44,100	$55,125	$66,150
5	$25,790	$34,301	$38,685	$51,580	$64,475	$77,370
6	$29,530	$39,275	$44,295	$59,060	$73,825	$88,590
7	$33,270	$44,249	$49,905	$66,540	$83,175	$99,810
8	$37,010	$49,223	$55,515	$74,020	$92,525	$111,030
For each additional family member	$3,740	$4,974	$5,610	$7,480	$9,350	$11,220

What´s Next?

Fill out the program enrollment form located to your right. If you don’t see an enrollment form available please call Allergan, Inc. program directly. After filling out the enrollment form please bring the form to your doctor for proper signatures and procedures. Do not forget a self stamped envelope for them to mail in your application to the program.

Other Tips

If you have any questions please call the Allergan, Inc. program directly
Fill out as much of the information on the enrollment form as possible. The more information you have pre-filled the easier the progrm is to enroll in
Write down the refill dates for your program and set a reminder here on PatientAssistance.com so that you don’t run out of medication.
Do not write messy on your forms as this will delay any response
Call and write thank you notes to Allergan, Inc. program. Without their help millions of people will be without medication.

PAP Links:

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Website:

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Address:

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Phone:
Fax:

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List of Medications

Alphagan P Solution 0.1%, 0.15% (brimonidine), Combigan Ophthalmic Solution 10ml (brimonidine Tartrate/timolol Maleate), Lumigan Ophthalmic Solution 0.03% (bimatoprost), Restasis Ophthalmic Emulsion 0.05% (cyclosporine Ophthalmic), Sanctura XR Extended Release Tablets 60mg (trosplum Choride), Tazorac Cream 0.05%, 0.1% (tazarotene Topical), Tazorac Gel 0.05%, 0.1% (tazarotene Topical)

Forms and other information are Copyright © Allergan Patient Assistance Program

While you are waiting to qualify for your free medication please try a Free Discount Drug Card > Click Here

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