| |
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)
|
| |
|
|