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Equetro Patient Assistance Program
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119 Cherry Hill Road, Suite 310
Parsippany, NJ 07054
Phone
:
(866)982-5438
Fax:
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Eligibility
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The patient must have no prescription coverage, be at or below 200% of the Federal Poverty Level and be a US citizen. |
| Who Can Apply
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Anyone requesting assistance can call to have an application faxed or mailed. An application can also be downloaded. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Up to 3 months supply |
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Ship To
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Doctor's office |
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Note
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|
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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.
|
| Equetro Extended-Release Capsules |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
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Marplan Patient Assistance Program
|
119 Cherry Hill Rd, Suite 310
Parsippany, NJ 07054
Phone
:
(866)982-5438
Fax:
|
|
Eligibility
|
| > |
Patients must have no prescription coverage, be at or below 200% of the Federal Poverty Level and be a US citizen or legal resident. |
| Who Can Apply
|
| > |
Anyone interested can call to have an application faxed or mailed. An application can also be downloaded. |
|
Required
|
| > |
Doctors must complete a section of the application, sign and attach a prescription. Patients must complete a section, sign and attach a copy of proof of income. The application must then be mailed. |
|
Supply
|
| > |
Up to 3 months supply |
|
Ship To
|
| > |
Doctor's office |
|
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.
|
| Marplan tablet |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
|
|