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ProThelial Sample Program
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1768 Storrs Road
Mansfield, CT 06268
Phone
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(860)477-0961
Fax:
(860)477-0962
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Eligibility
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This program is for Healthcare Professionals Only.
Patients insurance status and income will be considered on a case by case basis. Patients with Medicare Part D will be considered on an exception basis. Patient's must have a medically appropriate diagnosis. Residency requirements have not been specified for this program. |
| Who Can Apply
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Healthcare providers can call to have an application faxed or download the application. |
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Required
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Doctors must complete and sign a section of the application. Patients must complete and sign a section of the application. |
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Supply
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Amount requested is sent |
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Ship To
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Doctor's office or patient's home |
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Note
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ProThelial™ is indicated for the management (treatment and prevention) of oral mucositis of any cause. |
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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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| Prothelial paste |
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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 |
(Requires Acrobat Reader) 
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