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Patient Assistance Information

 
1 Program for Restasis Ophthalmic Emulsion
 
 
Allergan Patient Assistance Program

Patient Assistance Program
PO Box 42847
Cincinnati, OH 45242
Phone : (800) 553-6783
Fax: (513)618-0054
Eligibility
> The Patient Assistance Program provides assistance to uninsured patients that cannot afford their medications. Annual household income limits do apply but each case is reviewed on an individual basis. Patients must reside in the U.S. and be under the care of a U.S. based physician.
Who Can Apply
> The physician's office may apply on the patient's behalf or patients can also initiate the application process online.
Required
> Physician may complete the application on line sign & fax the request form attesting to the need of the patient. The physician's state license or Optometrist's TPA number is required. Documentation of the patient’s gross annual household income is required.
Supply
> Up to a 6 month supply. Reorders can be placed in the fifth month.
Ship To
> Medication is shipped to the physician's office for dispensing to the patient.
Note
> The application must be completed in its entirety, signed by the Patient and Physician, and faxed or mailed in with appropriate documentation (see instruction page of the application).
 
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
 
Restasis Ophthalmic Emulsion
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Allergan PAP Application
(Requires Acrobat Reader