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Torisel Reimbursement Support and Patient Assistance Program
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PO Box 220907
Charlotte, NC 28222
Phone
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866-993-8466
Fax:
866-993-8411
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Eligibility
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The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor. |
| Who Can Apply
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The doctor/doctor's office should call for an application. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section of the enrollment form and sign it. |
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Supply
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Ship To
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Doctor's office |
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Note
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The doctor/doctor's office should call for an application. |
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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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| Mylotarg |
| Neumega |
| Torisel Injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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