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| 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 NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income required as proof of income | |||||||||||||||||||||||
| Other Requirements | Require POI every 3 YEARS | |||||||||||||||||||||||
| Delivery of Medication | ||||||||||||||||||||||||
| Ship Time | 30 days | |||||||||||||||||||||||
| Delivery Options | Can NOT be delivered directly to the patient Can be delivered directly to the doctor | |||||||||||||||||||||||
| 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 accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail | |||||||||||||||||||||||
| Refills | Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can NOT apply for refills via phone Can apply for refills via fax Can apply for refills via mail | |||||||||||||||||||||||
| Re-Applications | Re-Applications accepted Patients can apply for Re-Applications Doctors can apply for Re-Applications Advocates can apply for Re-Applications Can NOT Re-Apply via phone Can Re-Apply via fax Can Re-Apply via mail | |||||||||||||||||||||||
| Appeals | Income Appeals NOT accepted Patients can NOT apply for Income Appeals Doctors can NOT apply for Income Appeals Advocates can NOT apply for Income Appeals Hardship Appeals accepted Patients can apply for Hardship Appeals Doctors can apply for Hardship Appeals Advocates can apply for Hardship Appeals Can NOT apply for an appeal via phone Can apply via fax Can 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 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 eligible if they are accepting Medicare Patients are NOT eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients are NOT eligible if Medicare coverage has been exhausted | |||||||||||||||||||||||
| Appeals | ||||||||||||||||||||||||
| Conditions | Appeals will consider out-of-pocket expenses Appeals will consider total medical expenses Appeals must be made after the patient has been denied | |||||||||||||||||||||||
| Other Medications | ||||||||||||||||||||||||
| Other Medications available in this program |
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