Simbrinza

Indicated For

Open-angle glaucoma, ocular hypertension

About This Medication

# Alcon Cares Patient Assistance Program: How to Get Simbrinza at Low or No Cost ## About This Program The **Alcon Cares Patient Assistance Program** is designed to help eligible patients access **Simbrinza** (brinzolamide/brimonidine tartrate ophthalmic suspension) at no cost when they cannot afford their medication.[1][2] Simbrinza is a prescription eye drop used to treat elevated intraocular pressure in patients with open-angle glaucoma or ocular hypertension. This program removes financial barriers so you can continue your eye care treatment without interruption. ## Who Qualifies for This Program? You may be eligible for the Alcon Cares Patient Assistance Program if you meet ALL of the following criteria: - You are a **US resident**[1] - You have **limited or no private prescription insurance coverage**[1] - You do **not qualify for local, state, or federal prescription programs**[2] - You are **not enrolled in Medicare Part D**[2] - Your healthcare provider believes you cannot afford your medication[5] - You have a valid prescription from a US-licensed healthcare provider[2] The program is specifically designed for patients experiencing genuine financial hardship who lack adequate prescription coverage. Your healthcare provider plays an important role in determining your eligibility and must support your application. ## Income Eligibility While specific income thresholds are not publicly listed, the program evaluates eligibility based on **household income, assets, and financial hardship**.[2] The application process screens for these factors comprehensively. If you have concerns about whether your income qualifies, you can discuss this with your healthcare provider or call the program directly at **1-800-222-8103** to speak with a representative who can provide guidance specific to your situation.[2] ## Insurance Requirements This program is available only to patients with: - **No private prescription insurance**, OR - **Limited private prescription insurance** that does not adequately cover Simbrinza **Important Medicare Note:** If you are enrolled in **Medicare Part D**, you are generally **not eligible** for this program.[2] Medicare Part D is considered prescription coverage, and the program requires that you have no or limited coverage. If you have questions about how your Medicare Part D plan affects your eligibility, call **1-800-222-8103**.[2] ## How to Apply: Step-by-Step ### Step 1: Contact Your Healthcare Provider Your eye care provider (ophthalmologist or optometrist) must initiate the application process on your behalf.[2] Contact their office and ask about the Alcon Cares Patient Assistance Program for Simbrinza. Your provider can request the application form directly from Alcon Cares, Inc. ### Step 2: Complete Your Section of the Application You will need to complete Section 1 of the application form, which includes:[2] - Your full name, date of birth, and Social Security number - Current address and phone number - Information about any existing insurance coverage - Medicare eligibility status - Household composition and income information ### Step 3: Gather Required Financial Documentation You must provide **copies of your most recent Federal Income Tax return or other proof of income** for you and all household members.[2] This documentation is essential for the program to assess your financial need. Acceptable documents may include: - Federal tax returns (most recent year) - Pay stubs - Benefit statements (Social Security, disability, etc.) - Bank statements showing income - Other official proof of household income ### Step 4: Your Healthcare Provider Completes Their Section Your healthcare provider must complete Section 2 of the application, confirming that you are their patient and that they believe you cannot afford your medication.[2] The provider's signature and clinical judgment are required for the application to be valid. ### Step 5: Submit the Completed Application Once both you and your healthcare provider have completed the application, submit it by:[2] - **Faxing** to: **800-554-2660**, OR - **Mailing** to: Alcon Cares, Inc. TB3-4 • 6201 South Freeway Fort Worth, TX 76134-0450 **Important:** Incomplete or illegible applications will not be processed and will be returned to you.[2] ## Application Timeline and Medication Delivery ### Processing Time The program does not publicly specify an exact processing timeline. Once your application is received, Alcon Cares will review it for completeness and eligibility. If you need to check on your application status, call **1-800-222-8103**.[2] ### Medication Delivery Once approved, your Simbrinza will be **shipped directly to you** at no cost.[1] The program provides up to a **six-month supply** per shipment.[2] If you need a second six-month supply, you must coordinate with your healthcare provider to request it before your current supply runs out. ### Approval Duration An approved application is valid for **one year**.[2] After one year, you will need to reauthorize your enrollment (see Reauthorization section below). ## Reauthorization: Renewing Your Enrollment Your approval lasts for **one year**.[2] To continue receiving Simbrinza through the program, you must reauthorize before your approval expires. To renew: 1. Contact your healthcare provider to confirm you still need the medication 2. Check the renewal box on page 1 of your original application and fill in the current date[2] 3. Fax or mail the updated page 1 and page 2 of your original application to the same fax or mailing address 4. Include any updated financial documentation if your household situation has changed If there are no changes to your application or the products you need, you can simply submit the renewal pages without completing the entire form again. ## What If Your Application Is Denied? If your application is denied, **Alcon Cares will send you a letter explaining the reasons for denial** and what actions you can take to resubmit.[2] Common reasons for denial include: - Incomplete or illegible application - Income exceeding program limits - Existing prescription insurance coverage - Enrollment in Medicare Part D - Not meeting other eligibility criteria If the letter indicates that required criteria are not met, do not resubmit the application, as you would not qualify. However, if the denial was due to incomplete information, you can correct and resubmit. ## If You Have Questions or Need Support For assistance with the application process or to check your application status, contact: - **Phone:** **1-800-222-8103** (option 2)[2] - **Hours:** Monday–Friday, 8 AM–5 PM CST[1] - **Alternative:** Contact your healthcare provider, who can also help obtain the application or answer questions about the program There are **no charges at all** to patients or healthcare providers for participation in this program.[2] ## Important Disclaimer This guide provides general information about the Alcon Cares Patient Assistance Program based on publicly available program guidelines. Eligibility requirements, application procedures, and program benefits may change. For the most current and accurate information, contact the program directly at 1-800-222-8103 or speak with your healthcare provider. This guide is not a guarantee of program enrollment or medication delivery. Always consult with your healthcare provider about your treatment options and medication needs.

Program information last verified: March 29, 2026