|
Photofrin Patient Assistance Program
|
2730 S. Edmonds Lane, Suite 300
Lewisville, TX 75067
Phone
:
855-215-2720
Fax:
855-314-3943
|
Eligibility
|
> |
This program provides brand name medications at no or low cost to patients with no insurance coverage for the needed medication. Medicare Part D recipients are not eligible. Patients must be at or below 200% of the federal poverty level, must have a medically appropriate condition/diagnosis and be a us citizen or legal entrant. |
Who Can Apply
|
> |
Patients or healthcare providers can call to have an application faxed or it can be downloaded. |
Required
|
> |
Patients must complete a section of the application, sign and attach proof of income. Doctors must also complete and sign a section. The application can then be faxed or mailed. |
Supply
|
> |
Not specified |
Ship To
|
> |
Not specified |
Note
|
> |
|
|
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. |
Photofrin injection |
|
Printable Application Forms Applications that patients can fill out and bring to their doctor. |
Download printable Form |
Download printable Form |
(Requires Acrobat Reader)
|
|
|