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TEVA Patient Assistance Program for Clozapine
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Teva Patient Assistance Program for Clozapine
50 NW 176th Street
Miami, FL 33169
Phone
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800-507-8334
Ext OPT 3
Fax:
800-507-8339
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Eligibility
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The patient must have no prescription coverage for any medications and meet income guidelines that are not disclosed. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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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 and sign the application. |
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Supply
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Ship To
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Hospital, Doctor's office, Patient's home or Pharmacy |
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Note
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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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.
| | Clozapine Tablets |
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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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Azilect Patient Assistance Program
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PO Box 139
Somerville, NJ 08876
Phone
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866-217-7163
Fax:
866-838-5832
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 350% of the Federal Poverty Level. The patient must also be a US citizen or legal resident. |
| Who Can Apply
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The doctor or patient can call to request an application be faxed or mailed. |
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Required
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The doctor must fill out a section, sign the application and attach required documents.The patient must fill out a section, sign the application and attach required documents. |
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Supply
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Not specified |
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Ship To
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Patient's home, unless otherwise noted |
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Note
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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.
| | Azilect Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | Download printable Form | | (Requires Acrobat Reader)
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Copaxone Patient Assistance Program
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Shared Solutions
901 East 104th Street, Suite 900
Kansas City, MO 64131
Phone
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(800)887-8100
Fax:
Not Applicable
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Eligibility
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The patient must not have public insurance but may have private insurance. The patient must meet income guidelines that are not disclosed and must also be a US citizen. |
| Who Can Apply
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Patients or healthcare providers can call. |
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Required
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The doctor must give a prescription to the patient. The patient must fill out a section of the application and sign. |
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Supply
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Up to a 30 or 90 day supply |
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Ship To
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Patient's home |
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Note
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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.
| | Copaxone (glatiramer acetate) |
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Adasuve REMS/Reimbursement Program
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,
Phone
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800-292-4283
Fax:
855-755-0493
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Eligibility
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Patients must meet income requirements that have not been disclosed and be a US resident. |
| Who Can Apply
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Patients can complete the application online or by phone. |
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Required
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Patients must inform their doctor that they are in need. Doctors must enroll in the program. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY: ADASUVE will be dispensed only to patients in healthcare facilities that are enrolled in the ADASUVE REMS Program. |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | | Download printable Form | | Download printable Form | | (Requires Acrobat Reader)
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CORE Patient Assistance Program
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PO Box 7588
Overland Park, KS 66207
Phone
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888-587-3263
Fax:
866-676-4073
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Eligibility
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Patients must have no prescription coverage for the needed medication, be at or below 500% of the Federal Poverty Level, have a medically appropriate diagnosis/condition and be a citizen or legal resident. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. It can also be downloaded. |
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Required
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Doctors must complete a section and sign. Patients must complete a section, sign, attach a copy of proof of income, and attach front and back copy of insurance card. |
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Supply
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Not specified |
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Ship To
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Doctor's office |
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Note
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Contact program for Spanish 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.
| | Bendeka | | Granix injection | | Synribo powder; subcutaneous | | Treanda injection | | Trisenox injection |
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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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TEVACares Foundation Patient Assistance Program
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PO Box 52028
Phoenix, AZ 85072
Phone
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877-237-4881
Fax:
877-438-4404
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Eligibility
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Patients must have no prescription coverage for the needed medication, including Medicare Part D. Income requirements for this program are based on the Federal Poverty Level. Patients must be a citizen or US resident. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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Ship To
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Doctor's office or patient's home |
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Note
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The CephalonCares Foundation Patient Assistance Program for Fentora, Gabitril, Nuvigil and Tev-Tropin and the TEVA Assistance Program are now known as the TEVA Cares Foundation Patient Assistance Program.
Contact program for Spanish 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.
| | Fentora (fentanyl buccal) | | Gabitril (tiagabine hydrochloride) | | Galzin (zinc acetate) | | Nuvigil tablet | | Orap (pimozide) | | Proair HFA Inhaler | | Proglycem oral suspension | | QNASL aerosol; nasal | | QVAR aerosol; inhalation |
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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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