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Patient Assistance Information

 
2 Programs for Cipro HC Ophthalmic Solution
 
 
Alcon Patient Assistance Program

TB3 4
6201 South Freeway
Forth Worth, TX 76134-0450
Phone : 800-222-8103 Ext OPT 1
Fax: 800-554-2660
Eligibility
> 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
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> 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.
Supply
>
Ship To
> Either Doctor's office or Patient's home
Note
> Each request is subject to approval and fulfillment is based upon current available resources.
 
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.
 
Cipro HC Ophthalmic Solution
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Bayer Patient Assistance Program

6 West Belt
W66
Wayne, NJ 07470-6806
Phone : 888-842-2937 Ext OPT 7 or 3
Fax: 973-305-3545
Eligibility
> The patient cannot have prescription insurance, be ineligible for any federal or state programs and the patient must also also have limited financial resources. The patient must be a US citizen or legal US resident.
Who Can Apply
> The patient or doctor should call for an application.
Required
> 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.
Supply
> Up to a 90-day supply
Ship To
> Doctor's office
Note
> The patient or doctor 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.
 
Cipro HC Ophthalmic Solution
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
Download printable Form Angeliq Form
Download printable Form Climara Form
Download printable Form Climara Pro Form
(Requires Acrobat Reader