Viberzi Prescription Assistance Programs

Viberzi: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Viberzi. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not or go to the program website.

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Allergan Patient Assistance Program

(Program 1 of 1 — Scroll down to see them all )

Provided by: Allergan, Inc.
PO Box 66764 St. Louis, MO 63166
TEL: 844-424-6727
FAX: 844-708-0036
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
  • Viberzi tablet (eluxadoline tablet)
Eligibility Requirements
  • Insurance Status Contact program for details.
  • Those with Part D Elibible? Yes, but have been denied or are ineligible for Low Income Subsidy
  • Income Not disclosed
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? The patient must be a US citizen or legal entrant.
  • Obtaining Call or download
  • Receiving Faxed or downloaded from website
  • Returning The completed application must be faxed or mailed from the doctor's office.
  • Doctor's Action Complete section, sign, attach required documents
  • Applicant's Action Complete section, sign, attach required documents
  • Decision Communicated Patient and Doctor are notified
  • Decision Timeframe 5-7 business days
  • Amount/Supply Up to 90 day supply
  • Sent To Doctor's office or pharmacy
  • Delivery Time Within 10 days
  • Refill Proces Doctor/Doctor's office must contact the Program
  • Limit Varies
  • Re-application Those with Medicare Part D reapply Jan 1st, all others reapply on anniversary date of when they enrolled
Additional Information
Proof of income is needed annually
Updated September 5, 2019

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

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