Allergan Patient Assistance Program


Contact Information
Allergan Patient Assistance Program
PO Box 6623
Somerset, NJ 08875
1-(800) 553-6783 (phone)
1-(732) 507-7636 (fax)
How to Apply:
Select one of the links below to download the application or go to the program site for more information on how to apply. Once you fill out your application, send it to the address on the application. Do NOT send it to RxResource.
The objective of the Patient Assistance Program is to provide assistance to patients who are not eligible for Medicare Part D and are without another form of drug coverage and cannot afford their medications. Patients must reside in the United States and be under the care of a U.S. based physician and not be eligible for drug coverage by any private or public assistance program such as Medicare or Medicaid. Annual household income limits do apply but each case is reviewed on an individual basis.
Other Information:
Who Can Apply: Physician's office may apply on patient's behalf. Required: Physician may complete the application on line sign & fax the request form attesting to need of the patient. Physician's state license or Optometrist's TPA number is required. Patient's signature is required as well as proof of income Supply: 6 month supply; reorder after 5 months. Ship To: Physician's Office, to be provided to the patient at the Physician's Office. Note: Patient request forms must be filled out completely, signed by the Physician, and faxed or mailed in with appropriate proof of need. (see instruction page of the application)
Product(s) covered by program:
  • Alphagan® P
  • Lumigan®
  • Restasis®
  • Tazorac® Cream / Gel