| Pharmaceutical Company | Allergan Patient Assistance Program |
| Program Address | c/o Physician Services (T1-2G) 2525 Dupont Drive. P O Box 19534 Irvine, CA 92623-95534 |
| Toll Free Phone Number | 800-347-4500 |
| Alternate Phone Number | None |
| Fax Number | None |
| Guidelines and Notes | Household income must be less than $12,000 for a family of one-two members or less than $19,000 for a family of three and the patient must have no prescription insurance. |
| Initiating Enrollment | Anyone can register the patient by phone. The form is sent only to the ophthalmologists or optomitrists. |
| Health Provider's Role | The doctor completes the form including DEA number, signs, and mails the form. Alternatively, the physician may send on office stationary a letter including the date of the request, state license number, patient's phone number, name of product, strength and size, an original signature. |
| Patient's Role | Makes the physician aware of inability to buy the medications and lack of prescription insurance. |
| How Dispensed | Prescription drugs are sent to the physician's office. Over-the-counter drugs may be sent directly tot he patient if so requested and the patient's address is sent with the request. |
| Amount Dispensed | Vaires, depending on the medicine requested |
| Estimated Response Time | Not specified |
| Refills | Use a new appliccation or write another letter |
| Limit | Unspecified |