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Patient Assistance Information

Program Sponsored By Romark Laboratories (External Link)
Romark Laboratories Patient Assistance Program for Alinia

3000 Bayport Drive
Suite 200
Tampa, FL 33607
Phone : 813-282-8544
Fax: 813-282-1162
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application.
> The doctor must fill out a section, sign the application and attach a copy of the DEA or State License number.The patient must fill out a section, sign the application and attach a denial letter from Medicaid.
Ship To
> Doctor's office
> Eligibility determined on a case-by-case basis. Contact program for Spanish 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.
Alinia Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader