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Patient Assistance Information

 
 
 
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.
 
Azopt Suspension
Betoptic S Othphalmic
Bion Tears eye drops
Carteolol HCl opthalmic solution
Ciloxan Opthalmic Ointment
Ciloxan Solution
Cipro HC Ophthalmic Solution
Ciprodex Suspension
DuoTrav Eye Drops 2.5mL
Econopred Plus Suspension
Flarex Suspension
I-Caps Eye Vitamin AREDS Formula Softgels
I-Caps Lutein & Zeaxanthin Formula Tablets
I-Caps Multivitamin Formula Tablets
Iopidine Suspension
Isopto Carbachol Solution
Isopto Carpine Ophthalmic Drops
Levobunolol HCl Ophthalmic Solution
Maxitrol Suspension
Metipranolol Eye Drop
Nevanac Ophthalmic Solution 0.1%
Pataday Ophthalmic Solution 0.2%
Patanol Ophthalmic Solution 0.1%
Pilopine HS Gel
Systane Ophthalmic Drops
Tears Naturale Forte Eye Drops
Tears Naturale Free Lubricant Ophthalmic Drops
Tears Naturale PM Ophthalmic Ointment
Tobradex Ophthalmic Ointment
Tobradex Ophthalmic Suspension
Unisol 4 Saline Oral Solution
Vexol Suspension
Vigamox Solution
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader)