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| Drug Information | ||||||||||||||||||
| Drug | Tazorac Gel .05% | |||||||||||||||||
| Class | psoriasis | |||||||||||||||||
| Topic | Skin | |||||||||||||||||
| Program Contact Info / Application Submission | ||||||||||||||||||
| Program | Allergan Patient Assistance Program | |||||||||||||||||
| Company | Allergan | |||||||||||||||||
| Form | Download PDF | |||||||||||||||||
| Address | Box 4015 Clinton, NJ 08809 | |||||||||||||||||
| Phone | 800-553-6783 | |||||||||||||||||
| Fax | 908-713-7736 | |||||||||||||||||
| Website | http://www.allergan.com/site/practitioners/content_download.asp?id=&largeText= | |||||||||||||||||
| Program Details | ||||||||||||||||||
| Details | A 6-month supply of the medication is sent to the doctor�s office. For refills, a copy of the same application with new dates is needed. A new application with documentation is needed once a year. | |||||||||||||||||
| Program Requirements | ||||||||||||||||||
| Information | The doctor must fill out their section and sign the application. The patient must also fill out their section, sign the application and attach proof of income. | |||||||||||||||||
| Details | Insurance card required Drivers license required Proof of Income NOT required Copy of most recent tax return such as 1040, 1099 NOT required as proof of income Letter from Doctor stating zero incomeNOT required as proof of income Form 4506T (If taxes were not filed) required as proof of income Most recent bank statements NOT required as proof of income Most recent check/check stub copy NOT required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement NOT required as proof of income Award Letter for Alimony/Child Support, Unemployment NOT required as proof of income Notarized statement from patient stating zero income NOT required as proof of income | |||||||||||||||||
| Other Requirements | Require POI every 3 YEARS | |||||||||||||||||
| Delivery of Medication | ||||||||||||||||||
| Ship Time | 30 days | |||||||||||||||||
| Delivery Options | Can be delivered directly to the patient Can NOT be delivered directly to the doctor Shipped as a voucher card | |||||||||||||||||
| Application Process | ||||||||||||||||||
| App Process | The doctor or doctor�s office can call and request an application. Applications are sent to the doctor�s office. Completed applications can be faxed or mailed back. Medication is usually sent within 30 days of acceptance. | |||||||||||||||||
| New Applications | New applications NOT accepted Patients can NOT apply directly to the program Doctors can NOT apply directly to the program Advocates can NOT apply directly to the program Can apply for a new application via phone Can NOT apply for a new application via fax Can NOT apply for a new application via mail | |||||||||||||||||
| Refills | Refills NOT accepted Patients can NOT apply for refills Doctors can NOT apply for refills Advocates can NOT apply for refills Can apply for refills via phone Can NOT apply for refills via fax Can NOT apply for refills via mail | |||||||||||||||||
| Re-Applications | Re-Applications NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can Re-Apply via phone Can NOT Re-Apply via fax Can NOT Re-Apply via mail | |||||||||||||||||
| Appeals | Income Appeals accepted Patients can apply for Income Appeals Doctors can apply for Income Appeals Advocates can apply for Income Appeals Hardship Appeals NOT accepted Patients can NOT apply for Hardship Appeals Doctors can NOT apply for Hardship Appeals Advocates can NOT apply for Hardship Appeals Can apply for an appeal via phone Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail | |||||||||||||||||
| Eligibility | ||||||||||||||||||
| Eligibility | The patient must have no prescription coverage for the medication requested and their income must be at or below 165% of the Federal Poverty Level. The patient must be a US resident. Patients who are enrolled in Medicare Part D may still be able to enroll in this program. No more than two products may be requested in a six-month period. Restasis can be requested every 3 months. If more than 2 products are requested on one application, the application maybe rejected. | |||||||||||||||||
| Limitations | Patients are NOT eligible if LIS is denied Patients may be eligible with existing prescription coverage on a case by case basis Patients may be eligible if prescription is not covered on a case by case basis Patients may be eligible if prescription coverage has been exhausted on a case by case basis Patients are NOT eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are eligible if the medication is not covered under Medicare Patients are eligible if Medicare coverage has been exhausted | |||||||||||||||||
| Appeals | ||||||||||||||||||
| Conditions | Appeals will NOT consider out-of-pocket expenses Appeals will NOT consider total medical expenses Appeals may be made before the patient has been denied | |||||||||||||||||
| Other Medications | ||||||||||||||||||
| Other Medications available in this program |
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