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GTX Patient Assistance Program
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PO Box 8203
Somerville, NJ 08876
Phone
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866-325-8231
Fax:
866-694-2546
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Eligibility
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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
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With the patient's permission, anyone concerned can call for an application. |
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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, sign the application and attach proof of income. |
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Supply
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Up to a 90-day supply |
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Ship To
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Doctor's office |
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Note
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With the patient's permission, anyone concerned can call for an 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.
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| Fareston Tablets |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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