Acuvail

Allergan Patient Assistance Program Patient Guide: How to Get Acuvail at Low or No Cost

About This Program

The Allergan Patient Assistance Program, operated by AbbVie, helps eligible patients in the United States obtain Acuvail (ketorolac tromethamine) at no cost when they cannot afford their medication. This program is designed to ensure that financial hardship does not prevent you from accessing the eye care medication your doctor has prescribed.

About Acuvail

Acuvail is a nonsteroidal anti-inflammatory drug (NSAID) used to treat eye pain and inflammation. It is commonly prescribed following eye surgery or for other ophthalmologic conditions. The medication works by reducing inflammation and pain in the eye.

Who Can Qualify

You may be eligible for the Allergan Patient Assistance Program if you meet these criteria:

• You are a U.S. resident
• You have a valid prescription for Acuvail from a licensed healthcare provider
• You have qualifying financial need and limited or no health insurance coverage for this medication
• You are not currently enrolled in a federal or state pharmaceutical assistance program for the same medication
• If you are enrolled in Medicare Part D, you must have been denied the Low-Income Subsidy (LIS) by the Social Security Administration

Income Eligibility

The program serves patients at or below 400% of the current Federal Poverty Level. While specific income thresholds are not publicly listed, the program evaluates your household income based on current federal poverty guidelines. Your household size determines your eligibility threshold.

What counts as household income:

• Wages and salary
• Social Security benefits
• Disability benefits
• Veterans benefits
• Other regular monthly income

Insurance Requirements

You must have limited or no health insurance coverage for Acuvail to qualify. If you have private insurance or Medicare coverage, you may still be eligible if:

• Your insurance plan does not cover Acuvail
• Your out-of-pocket costs are prohibitively high
• You have been denied coverage by your insurance company

Important Medicare Note: If you are enrolled in Medicare Part D, you must first apply for and be denied the Low-Income Subsidy (LIS) before you can qualify for this patient assistance program. You will need to submit your LIS denial letter with your application.

How to Apply: Step-by-Step

Step 1: Gather Required Documents

Before starting your application, collect the following:

• Proof of income (choose one):

  • Most recent U.S. income tax return (Form 1040, 1040A, 1040EZ, 1040NR, or 1040PR)
  • Social Security or Disability Award Letter or Benefit Statement
  • Recent pay stubs (typically last 2-3 months)
  • Bank statement showing monthly direct deposit
  • Monthly healthcare benefits statement

• Proof of residency (if required)

• Valid prescription from your licensed healthcare provider written for a three-month supply of Acuvail

• Medicare Part D denial letter (if applicable)

• Insurance information (policy numbers, group numbers, plan names)

Step 2: Complete the Application

You have two options for completing your application:

Option A: Work with Your Prescriber's Office

• Your doctor's office can help you complete and submit the application
• The prescriber must sign the application
• Your signature is also required

Option B: Apply Directly

• Download the application from the program website or request one by phone
• Complete all sections of the application form
• Have your prescriber sign the form
• Sign and date the form yourself

Step 3: Submit Your Application

Submit your completed application and all required documents by:

By Mail: Allergan Patient Assistance Program PO Box 66764 St. Louis, MO 63166

By Fax: 1-(844) 708-0036 (Note: Applications faxed must include the physician's fax banner)

By Phone: Call 1-(844) 424-6727 to request an application be mailed or faxed to you

Step 4: Wait for Approval Notification

Once the program receives your completed application, both you and your prescriber will be notified of your eligibility status. Keep a copy of your application for your records.

Timeline and Medication Delivery

Processing Time: Allow approximately 4 weeks for your application to be reviewed and processed.

Medication Supply: Once approved, you will receive a 90-day supply of Acuvail, which will be shipped to your prescriber's office. Your prescriber will then dispense the medication to you.

Enrollment Period: If approved, you are eligible to receive medication from the program for a 12-month calendar year term.

Refills: The program will automatically send you a new 90-day supply every three months during your 12-month enrollment period, as long as your prescription remains valid.

Important Program Rules

While enrolled in the Allergan Patient Assistance Program, you must:

• Not purchase Acuvail under your Medicare plan
• Not submit insurance claims for the medication provided through the program
• Not seek true out-of-pocket (TrOOP) credit for the medication
• Notify the program in writing if your circumstances change

Reauthorization and Renewal

Your enrollment in the program lasts for 12 months. To continue receiving assistance after your enrollment period ends, you must:

• Submit a new application
• Provide updated proof of income
• Obtain a new prescription from your healthcare provider with a current date
• Resubmit all required documentation

The program requires new signatures and current prescriptions for each annual renewal, even if your financial situation has not changed.

What If Your Application Is Denied?

If your application is denied, you have several options:

• Request clarification: Contact the program at 1-(844) 424-6727 to understand why you were denied
• Reapply: If your circumstances have changed, you may reapply with updated documentation
• Explore alternatives: Ask your prescriber about generic versions of ketorolac or other treatment options
• Contact patient advocacy organizations: Organizations like the National Glaucoma Society may have additional resources
• Check state programs: Some states offer pharmaceutical assistance programs that may help

Important Disclaimer

This guide provides general information about the Allergan Patient Assistance Program. Program eligibility, requirements, and benefits may change. For the most current and accurate information, contact the program directly at 1-(844) 424-6727 or visit the official program website. Always consult with your healthcare provider about your treatment options and eligibility for assistance programs.