Simbrinza

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.