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Taiho Oncology Patient Support Program
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PO Box 30226
Bethesda, MD 20824
Phone
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844-824-4648
Fax:
844-287-2559
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Eligibility
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Patients with insurance, including Medicare Part D, may apply. Income requirements have not been disclosed. Patients must be a US resident. |
| Who Can Apply
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Patients and healthcare providers can call to have an application faxed, mailed or it can be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must also complete a section, sign and attach proof of income. |
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Supply
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Up to 30 day supply |
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Ship To
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Patient's home, unless otherwise noted |
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Note
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* Those with Medicare Part D must reapply January 1st. All others reapply on anniversary date of when they enrolled.
This program also provides reimbursement assistance. |
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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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| Lonsurf |
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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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