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MS One to One Patient Assistance Program
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One to One Support Services
PO Box 220790
Charlotte, NC 28222
Phone
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(855)676-6326
Fax:
(855)557-2478
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Eligibility
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Must be uninsured or rendered uninsured. Medicare PartD patients not eligible. Income must be at or below 500% of FPL. Must be US citizen or legal entrant. |
| Who Can Apply
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Call for application to be faxed or download from website. Application must be faxed back to company from Doctor's office. |
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Required
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Medically appropriate condition/diagnosis required. Doctor must complete section and sign. Patient must complete section, sign application and consent. Patient will be notified of decision. |
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Supply
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Amount/supply not specified. Refills are automatically sent out. Refill limit of 1 year. Company contacts patient about reapplying. |
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Ship To
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Ship to Patient's home. |
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Note
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Patient must have a US prescriber. |
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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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| Aubagio tablet |
| Lemtrada |
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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 MS One to One Patient Assistance Program |
(Requires Acrobat Reader) 
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