Allergan Patient Assistance Program

Find out if your medicine is in the Allergan Patient Assistance Program

Review our medicine list and download the application to apply.

Product Name

ACUVAIL® (ketorolac tromethamine ophthalmic solution) 0.45%
Download application form

AEROCHAMBER PLUS® FLOW-VU® aVHC Small/Medium Mask
Download application form

ALPHAGAN® P (brimonidine tartrate ophthalmic solution) 0.1%
Download application form

ARMOUR® THYROID (thyroid tablets, USP)
Download application form

AVYCAZ® (ceftazidime and avibactam) for injection, for intravenous use
Download application form

BOTOX® (onabotulinumtoxinA)
Download application form

BYSTOLIC® (nebivolol) tablets, for oral use
Download application form

CANASA® (mesalamine) rectal suppository
Download application form

CARAFATE® (sucralfate) suspension
Download application form

COMBIGAN® (brimonidine tartrate/timolol maleate ophthalmic solution) 0.2%/0.5
Download application form

CRINONE® (progesterone gel)
Download application form

DALVANCE® (dalbavancin) for injection, for intravenous use
Download application form

DELZICOL® (mesalamine) delayed-release capsules, for oral use
Download application form

DURYSTA™ (bimatoprost implant) 10 mcg
Download application form

ESTRACE® (estradiol vaginal cream, USP, 0.01%)
Download application form

FETZIMA® (levomilnacipran) extended-release capsules, for oral use
Download application form

GELNIQUE® (oxybutynin chloride) 10% topical gel
Download application form

INFED® (iron dextran Injection USP)
Download application form

LILETTA® (levonorgestrel-releasing intrauterine system)
Download application form

LINZESS® (linaclotide) capsules, for oral use
Download application form

LUMIGAN® 0.01% (bimatoprost ophthalmic solution 0.01%)
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MONUROL® (fosfomycin tromethamine) granules for oral solution
Download application form

NAMENDA® (memantine HCl) tablets, for oral use
Download application form

NAMENDA XR® (memantine hydrochloride) extended release capsules, for oral use
Download application form

NAMENDA® (memantine HCl) solution, for oral use
Download application form

NAMZARIC® (memantine hydrochloride extended-release and donepezil hydrochloride) capsules, for oral use
Download application form

OZURDEX® (dexamethasone intravitreal implant) 0.7 mg
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PRED FORTE® (prednisolone acetate ophthalmic suspension, USP) 1%
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PYLERA® (bismuth subcitrate potassium, metronidazole, tetracycline hydrochloride) capsules
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RAPAFLO® (silodosin) capsules
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RECTIV® (nitroglycerin) ointment 0.4%, for intra-anal use
Download application form

RESTASIS® (cyclosporine ophthalmic emulsion) 0.05%
Download application form

SAPHRIS® (asenapine) sublingual tablets
Download application form

SAVELLA®(milnacipran HCl) tablets
Download application form

TEFLARO® (ceftaroline fosamil) for injection, for intravenous use
Download application form

UBRELVY™ (ubrogepant) tablets, for oral use
Download application form

VIBERZI® (eluxadoline) tablets, for oral use, CIV
Download application form

VIIBRYD® (vilazodone hydrochloride) tablets, for oral use
Download application form

VRAYLAR® (cariprazine) capsules, for oral use
Download application form

XEN®
Download application form

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If you have any additional questions, please call us at 1-844-424-6727.