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Zyflo Connect Co-Pay Program
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Phone
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844-699-9356
Fax:
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Eligibility
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This program is intended for patients that are uninsured or are underinsured. Medicare Part D patients are not eligible for this program. Patients must be a US resident or resident of Puerto Rico. Income requirements for this program have not been disclosed. |
| Who Can Apply
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Patient must call to enroll once Doctor gives them the prescription. No online application available. |
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Required
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Supply
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30 day supply. Refill limit, refill process and re-application not specified. |
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Ship To
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Medication will be sent to Patient's home. |
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Note
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Out-of-pocket benefit equals an amount up to $2,500 per month with a maximum benefit of $30,000 per year. If a patient exceeds the maximum monthly benefit of $2,500, the patient will be responsible for the outstanding balance.
This program expires December 31, 2016 |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Zyflo CR tablet; extended release |
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Zyflo Connect Patient Assistance Program
|
,
Phone
:
844-699-9356
Fax:
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Eligibility
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Uninsured or Underinsured with no prescription coverage. Medicare part D eligibility is determined case by case. Income requirements for this program have not been disclosed. Patient must be a US citizen or legal entrant. |
| Who Can Apply
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Doctor/Doctor's office must call to request application, which will be sent to the Doctor's office and must be faxed back from the Doctor's office. No online application available. |
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Required
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Doctor must complete section and sign. Patient must complete section, sign, attach proof of income and other requested documentation. Patient and Doctor will be notified of acceptance. |
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Supply
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Amount/supply not specified. |
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Ship To
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Medication will be shipped to Patient's home in 1-2 business days. Refills are automatically sent out and patient must complete a new application every 12 months. |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY.
Physician must call to obtain an enrollment form. |
| |
Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
|
| Zyflo CR tablet; extended release |
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