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Patient Assistance Information

 
4 Programs Sponsored By Valeant Pharmaceuticals (External Link)
 
 
Coverage Plus Program

PO Box 220667
Charlotte, NC 28222
Phone : (888)607-7267
Fax: (855)735-4624
Eligibility
> Patients must have no prescription coverage including Medicare Part D, meet income requirements that have not been disclosed and reside in the US, Puerto Rico or the USVI.
Who Can Apply
> Patients or healthcare providers 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 also complete a section, sign and attach required documents. The application must then be faxed or mailed from the doctor's office.
Supply
> Not specified
Ship To
> Patient's home
Note
> This program also provides copay assistance.
 
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.
 
Cuprimine Capsules
Demser Capsules (metyrosine)
Syprine capsule
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Sculptra Patient Access Program

PO Box 430
Somerville, NJ 08876
Phone : (866)310-7551
Fax: (866)364-2016
Eligibility
> Patients must have no prescription coverage for the needed medication, meet income requirements that have not been disclosed, have an FDA-approved diagnosis and must be a US citizen or legal resident.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed.
Required
> Doctors must complete a section of the application, sign and attach a prescription. Patients must also complete a section of the application, sign, attach proof of income and attach insurance information. The application can then be faxed or mailed.
Supply
> Not specified
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.
 
Sculptra Injectable
 
 
 
Valeant Patient Assistance Program

PO Box 836
Somerville, NJ 08876
Phone : (866)268-7325
Fax: (866)217-7164
Eligibility
> Patient 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
> Patients or healthcare providers can call to have an application faxed or mailed.
Required
> Doctors must complete a section of the application, sign and attach a prescription. Patients must also complete a section and sign.
Supply
> Up to 90 day supply
Ship To
> Doctor's office
Note
> Wellbutrin XL IS NOT AVAILABLE FOR NEW PATIENTS. Call for information on the most recent medications as the list is subject to change.
 
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.
 
8-Mop Capsules
Ancobon Capsules
Atralin gel
Carac cream; topical
Cardizem LA tablet; extended release
Diastat AcuDial gel
Diastat gel; rectal
Edecrin tablet
Elidel Cream
Lodosyn tablet
Mephyton tablet
Mestinon Syrup
Mestinon tablet; timespan
Migranal
Mysoline
Oxsoralen-Ultra capsule
Targretin Capsules
Targretin gel; topical
Tasmar tablet
Zelapar tablet; orally disintegrating
Zovirax Cream
Zovirax Ointment
 
 
 
Wellbutrin XL Guarantee Program

Direct Success Pharmacy
PO Box 279
Sea Girt, NJ 08750
Phone : (800)520-3185
Fax:
Eligibility
> Insurance status will be considered on a case by case basis. Medicare Part D recipients are not eligible. Patients must meet income requirements that have not been disclosed, have a medically appropriate diagnosis/condition and must be treated by a US licensed healthcare provider.
Who Can Apply
> Patients or healthcare providers can call to apply.
Required
> Patients must call to enroll in the program.
Supply
> Not specified
Ship To
> Not specified
Note
> Eligibility determined on a case-by-case basis. Contact program for details.
 
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.
 
Wellbutrin XL Tablets