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Patient Assistance Information

 
2 Programs for Alrex Suspension
 
 
Bausch and Lomb Indigent Patient Program

1400 N Goodman St.
Rochester, NY 14609
Phone : 800-323-0000
Fax: Not Applicable
Eligibility
> The patient must have no prescription coverage for the requested medication and have an income at or below $19,600 for an individual or $26,400 for a family.
Who Can Apply
> The doctor/doctor's office should call for an application.
Required
> The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number.The patient must inform the doctor that s/he is in need.
Supply
>
Ship To
> Doctor's office
Note
> The doctor/doctor's office should call for an 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.
 
Alrex Suspension
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Xubex Pharmaceutical Services

PO Box 1244
Winter Park, FL 32790-1244
Phone : 866-699-8239
Fax: 407-671-7960
Eligibility
> Patients may have insurance. There are no income limits for this program. Patients must be a US resident.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The doctor needs to provide a prescription to the patient.The patient must fill out a section and sign the application.
Supply
> Varies
Ship To
> Either Doctor's office or Patient's home
Note
> No proof of income is required. Check the website for the exact price. This service is not currently available in Montana.
 
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.
 
Alrex Suspension
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader