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Alcon Patient Assistance Program
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TB3 4
6201 South Freeway
Forth Worth, TX 76134-0450
Phone
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800-222-8103
Ext OPT 1
Fax:
800-554-2660
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Eligibility
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The program is open to any private patient of a U.S. licensed healthcare provider who cannot afford their medication and does not have prescription insurance coverage or qualify for local, state or federal prescription programs unless such programs are documented to cause a financial hardship for the patient. Patients should qualify for the income test at 200% (two times) the current year's poverty level under the number of persons living in a household. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Ship To
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Either Doctor's office or Patient's home |
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Note
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Each request is subject to approval and fulfillment is based upon current available resources. |
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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.
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| Vexol Suspension |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
:
(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
| |
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.
|
| Vexol Suspension |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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