Irvine}

Allergan: Allergan Patient Assistance Program

http://www.rudramani.com

**Alphagan, Betagan, Celluvisc, Epifrin, Lacri-Lube, Pilagan, Propine, Refresh, Refresh Plus, Refresh PM, Tears Plus**
Pharmaceutical Company	Allergan
Program Address	Allergan Patient Assistance Program c/o Physician Services (T1-2G) 2525 Dupont Drive, POB 19534 Irvine, CA 92623-9534
Toll Free Phone Number	800-553-6783
Fax Number	n/a
Guidelines and Notes	Household income must be less than $12,000 for 1-2 people; less than 19,000 for 3 people, and patient must have no (private or public) prescription coverage.
Initiating Enrollment	They will only send applications to opthamologists or optomistrists (eye doctors). They will explain program to patients or others who call, but will only initiate application with above professionals, so patient's should call their eye doctors for help.
Health Provider's Role	Doctor completes, signs and sends form. Must fill in DEA#. Alternately, phyisician can send on letterhead: date of request, state license number, patient's name, name of product, strength & size and original signature.
Patient's Role	Income and (lack of prescription) insurance information needed. Patient signature not required.
How Dispensed	Sends medicine to doctor's office; will send OTC drugs to a patient if requested and if patient's address given.
Amount Dispensed	Usually a six month supply
Refills	Use entirely new application, just like first time.
Limit	Unspecified

http://www.rudramani.com