Botox Financial Assistance Guide

CHAMP has created the financial assistance guide below for anyone who has been prescribed Botox by their healthcare provider. Botox is a prescription medicine that is injected to prevent headaches for those living with chronic migraine disease. If you or someone you know requires help with paying for treatment, please review the details provided below to see if you qualify for the manufacturer’s financial assistance program and how best to access Botox.

Please note: This guide has not been produced or approved by the manufacturer of Botox. CHAMP does not endorse the use of any treatment over another, nor promote the use of this treatment for everyone living with migraine disease. Please consult your healthcare providers to determine if Botox is right for you.

Botox is covered by most insurers, but numerous patients still have out-of-pocket costs. If you are prescribed Botox, Allergan is offering financial assistance programs to help cover the costs. Each program is different and various programs exist to support patients with private or public insurance, as well as the uninsured.

I Have Been Prescribed Botox. What Financial Assistance Programs Exist to Help Me?

Private Insurance

I Have a Private/Commercial Insurance Plan

This category includes insurance plans provided through an employer, purchased with subsidy support from the Affordable Care Act (Obamacare) or purchased privately.

Highlights of the BOTOX Savings Program

Most insurance plans cover the majority of Botox costs and on average, you will pay $164 out of pocket per treatment*. Depending on your insurance coverage, eligible insured patients can receive reimbursement to help with remaining costs allowing you to pay $0. The Botox Savings Program covers out-of-pocket costs up to $700 per treatment for up to 5 treatments over a 12-month period. The yearly maximum savings limit is $3500 over a 12-month period. Please note that the Botox Savings Program covers the cost of the product and out-of-pocket costs for the injection but does not cover any associated office visit costs.

*Average cost per treatment based on allerganpricing.com.

Steps to Benefit from the Botox Savings Program

1 Your doctor writes you a prescription for Botox.
2 Visit botoxsavingsprogram.com to check eligibility and enroll in the program. You may be eligible if you’re 18 years or older, have commercial insurance and receive Botox treatment for chronic migraine. Botox is NOT approved for the treatment of episodic migraine disease.
3 Once you are enrolled and after you receive your first treatment, you will receive an Explanation of Benefits (EOB) from your insurance plan.
4 Visit botoxsavingsprogram.com to complete the online claim submission form. You must attach a scanned in copy of your EOB. Click submit.
5 If your claim is rejected, please contact 1-800-44-BOTOX.
6 If your claim is accepted and processed, you will receive a Botox Savings Program reimbursement check in as little as 2-3 weeks.

Medicare/Medicaid

I Have Medicare, Medicaid or other Government Insurance Plan

Currently, Allergan does not have a financial assistance program for patients whose medical insurance is provided by state or federal programs, like Medicare and Medicaid.

Uninsured

I Am Uninsured

The Botox Savings Program is not available to those patients who are uninsured or underinsured.

You may be eligible to receive Botox at no cost from the Allergan Patient Assistance Program if you meet the following requirements:

1 You are uninsured or underinsured
2 You are a resident of the United States or Puerto Rico
3 You have income less than or equal to 500% of the Federal Poverty Level

If you have this many people in your household…	…your household income must be equal to or below this much each year
1	$62,450
2	$84,550
3	$106,650
4	$128,750
5	$150,850
6	$172,950
7	$195,050
8	$217,150
Each additional person	Add $4,420

To apply, follow the simple steps below

1 Call the hotline at 1-800-44-BOTOX (1-800-442-6869). A Reimbursement Counselor can help answer questions and send you an application. Or partner with your healthcare provider to complete a Program Application online at botoxone.com/PatientAssistanceProgram.
2 Submit the completed application and supporting documents.
3 Once received and reviewed, we will send a Notification Letter and Product Request Form so you may begin your Botox treatment.

Need More Help

Where do I turn if I am not eligible for a financial assistance program?

The Patient Advocate Foundation (a CHAMP member organization) can be a helpful resource for patients and caregivers who are experiencing access challenges. PAF provides a suite of expert tips to help navigate insurance denials, appeals and common barriers at: patientadvocate.org/migrainematters.

PAF also offers one-on-one case management assistance through its dedicated Migraine Careline for people living with migraine who experience access challenges. The Migraine Careline provides assistance with navigating eligibility and enrollment in disability benefits and overcoming insurance coverage and financial burdens that impact patient access to care. All services are completely free and provided through phone and/or email communication. Visit migraine.pafcareline.org or call 866-688-3625 to speak with a case manager today.

BOTOX^® Basics

Item	Description
Brand Name	Botox
Biologic Name	onabotulinumtoxinA
Pharmaceutical Company	Allergan
Administration	Treatment session by injection in your doctor's office every 12 weeks
Indication	Adults living with chronic migraine disease (15 or more headache days per month, each lasting 4 hours or more) Botox is NOT approved for adults living with episodic migraine disease (14 or fewer headache days per month).
Full Prescribing Information	https://www.allergan.com/assets/pdf/botox_pi.pdf
Website	BOTOXchronicmigraine.com
Helpline	Call 1-800-44-Botox to speak to a Botox Savings Program Customer Service Manager, Monday-Friday, 8 am-8 pm ET or visit BotoxChronicMigraine.com for educational support and more.
Administration Training Available	No, Botox must be administered by a trained healthcare provider.
Home Delivery Available	No, your prescription is sent to your healthcare provider.

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