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Patient Assistance Information

 
Program Sponsored By GTX Inc (External Link)
 
 
GTX Patient Assistance Program

PO Box 8203
Somerville, NJ 08876
Phone : 866-325-8231
Fax: 866-694-2546
Eligibility
> The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below 225% of the Federal Poverty Level. The patient must also be a US resident.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
Supply
> Up to a 90-day supply
Ship To
> Doctor's office
Note
> With the patient's permission, anyone concerned can call for an application.
 
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.
 
Fareston Tablets
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader