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Xyrem Patient Assistance Program
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Phone
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866-997-3688
Fax:
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Eligibility
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The Xyrem Patient Assistance Program provides brand name medications at no or low cost and is intended for patients that have no prescription coverage for the needed medication. Income requirements for the program have not been disclosed. Patients must be a US citizen or legal resident. |
| Who Can Apply
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Patients must call for pre-screening. After pre-screening is complete an application will be sent the the patient if applicable. |
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Required
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The application must be completed, signed and faxed with proof of income and insurance information. The physician must also submit a prescription. The patient will be notified within 2-3 days. A new application must be submitted yearly. |
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Supply
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Supply varies. The patient must contact the company for refills. |
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Ship To
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The medication will be shipped overnight to the patient's home. |
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Note
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Both prescriber and patient must be registered with the XYREM REMS Program. |
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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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| sodium oxybate oral solution |
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Prialt Navigator Reimbursement and Access Program
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Phone
:
855-774-2581
Fax:
855-774-2583
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Eligibility
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The Prialt Navigator Reimbursement and Access Program is intended for patient that are uninsured or are underinsured. Medicare Part D patients are not eligible. Income requirements for this program have not been disclosed. Patients must be a US resident. Diagnosis and medical criteria have not been disclosed for this program. |
| Who Can Apply
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Doctor or doctor's office must call or download the application from the link below. |
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Required
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Application must be completed and signed by the doctor and the patient. Insurance information must be attached. The doctor will be notified within 2-3 days. The doctor must contact the company for refills. A new application and documentation are required every year. |
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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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Medication will be shipped to the doctor's office. |
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Note
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Resources for HEALTHCARE PROFESSIONAL ONLY.
The prescriber must enroll in the Navigator Program before enrolling patients. |
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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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| Prialt injectable; intrathecal |
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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 |
| Download printable Form |
(Requires Acrobat Reader) 
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Jumpstart Program
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1 Tara Boulevard, Suite 200
Nashua, NH 03062
Phone
:
888-837-4397
Fax:
877-256-2430
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Eligibility
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The Jumpstart Program provides brand name medications at no or low cost and is intended for patients that are privately insured. Patients may not be recipients of public insurance. Patients must be at or below 200% of the Federal Poverty Level, adjusted for household size. Patients must be a US citizen or possess a valid green card. |
| Who Can Apply
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Patient or doctors must call to obtain an application. |
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Required
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Application must be completed and signed by the doctor and the patient. Required documents must be attached and sent with the application. The doctor and the patient will be notified in 2-3 days. |
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Supply
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Up to a 1 month supply. |
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Ship To
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Medication will be shipped to the doctor's office or a specific location within 2 business days. |
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Note
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This is a one time program with a limit of 6 months. |
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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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| Defitelio |
| Erwinaze injection |
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