Prescription Eligibility Guidelines

Eligibility Guidelines

Patient eligibility is based both on the patient and healthcare provider’s responses to questions in the Program Application. The following general criteria apply:

  • Patient must submit a complete application
  • Healthcare provider must complete an application and provide a prescription to the Specialty Pharmacy
  • Patient must be a legal resident of the United States
  • Patient may not reside in a hospital, nursing home, correctional facility or court appointed program or facility
  • Patient cannot have government health insurance or private health insurance with a prescription benefit
  • Patient cannot participate in a State Pharmacy Assistance Program
  • Patient must meet annual gross income requirements to participate in the reduced cost or no cost

All products provided through this program must be prescribed and intended to be used on-label.

Prescription Refill Requests

Initial Product Shipment

& Refill Requests

Once your application is approved the 1st shipment of product will be sent to you from the program’s Specialty Pharmacy.


You must request each additional product shipment (i.e. refills) during the enrollment or re-enrollment period by submitting a refill request. This request must include your case number and correspond with an active prescription on file at our Specialty Pharmacy to be approved. You may be required to re-attest to the information you supplied on your initial application to complete the request.


Each shipment will include a 1-month supply of the product. A minimum of 7 business days is needed for each shipment to be processed.

Our products


Our products

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How To Apply


Apply to the program by submitting an application form with the following information about you:

  • Contact details
  • Health insurance coverage
  • Household annual gross income and size
  • Healthcare provider's contact information


We will contact your healthcare provider to request that they provide supplemental information completing the application and send a prescription for the product to our Specialty Pharmacy.


A Patient Assistance Coordinator will review your application and notify you of the decision. If approved, you will be contacted to complete enrollment.

Frequently Asked Questions

Underinsured patients meeting the eligibility guidelines receive Galderma product at a reduced or no cost after submitting a complete application

A Patient Assistance Coordinator will review your application to determine eligibility upon completion of the application by you and your healthcare provider. Make sure to review the Eligibility Guidelines section for the product type you are interested in before submitting an application.

You may not have government health insurance, private health insurance with a medical benefit or participate in a State Pharmacy Assistance Program to enroll in this program. More information in eligibility is located in the Eligibility Guidelines section.

Submit an application! The steps of the process can be located in the How To Apply section.

We try to make the application process as easy as possible. In most cases all required information can be provided in the Application and Refill form fields. An example of a document that may be needed to apply is a denial letter from your insurance (for Sculptra® requests only). You will be notified after applying to the program if additional documents are needed.

A single shipment of product will be shipped automatically following enrollment into the program. Refills or additional shipments of product will only be sent upon request from the enrolled patient. More information on this process can be located in the Review the Initial Product Shipment & Refill Requests.


Contact a Program Coordinator

Monday - Friday | 8:00 am - 5:00 pm CT | 1-855-431-3737