| |
Strativa Patient Assistance Program
|
PO Box 1475
Morristown, NJ 07962
Phone
:
(800)589-0841
Fax:
(973)644-3308
|
|
Eligibility
|
| > |
Patient must be a US resident and have a gross annual household income at or below 200% Federal Poverty Level for all eligible products with the exception of Megace ES which is set to 300% Federal Poverty Level. Additionally, Patient must not have any prescription coverage for the requested medication through any private or government funded prescription programs, including Medicare, Medicaid and Medicare Part D. |
| Who Can Apply
|
| > |
Enrollment can be initiated by Patients, Physicians, and Patient Advocates by calling the toll free support line or by faxing or mailing in the completed enrollment application. |
|
Required
|
| > |
Patient and Physician must provide a completed enrollment application with both the patient and Healthcare professional signatures and dates. Proof of gross annual household income is required. Acceptable documents include: Federal Income Tax (form 1040 or 1040EZ) with appropriate schedules (C and/or F) or Federal Income Tax Form 1099 or Yearly benefits statement (SSA, 1099, etc), award letter or bank statements showing automatic deposit for the current calendar year or current pay stub. (at least three) |
|
Supply
|
| > |
The following supply amounts will be shipped to the Healthcare provider’s office.
Nascobal – 60 day supply – Patient must reorder as needed
Oravig – 14 day supply – Patient must reorder as needed
Zuplenz – 10 day supply – Patient must reorder as needed
Megace ES Oral Suspension 625mg/5ml (megestrol) – 30 day supply – Patient must reorder every month |
|
Ship To
|
| > |
Medication will be shipped to the Healthcare Providers 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.
|
| Megace |
| Nascobal |
| Oravig |
| Zuplenz |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|