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Mylan Clozapine Patient Assistance Program
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781 Chestnut Ridge Rd
Morgantown, WV 26554
Phone
:
(800)395-3376
Fax:
(304)554-4713
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Eligibility
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The patient must have no prescription coverage for any medications and be financially unable to afford the medication. Patient must be at or below 200% federal poverty level. The patient must also have a medically appropriate diagnosis and be a citizen or legal resident. |
| Who Can Apply
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Anyone interested can call for an application and it can be faxed or mailed to them. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must complete a section, sign and provide proof of income and proof of lack in insurance. |
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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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Pharmacy |
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Note
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There are two steps and two sets of paperwork for this program. The first step is to register the patient, which is required for any patient taking Clozapine, regardless of insurance or financial situations. Call 800-843-9915 to register. This is a two-page form that the patient, physician and pharmacist must fill out.
Contact program for Spanish 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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| Clozapine 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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Mylan Miacalcin Injection Patient Assistance Program
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PO Box 219
Gloucester, MA 01930
Phone
:
(888)238-5694
Fax:
(888)246-6527
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Eligibility
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This program provides brand name medications at no or low cost for patients that have no prescription coverage. Patients must be at or below 200% of the federal poverty level. Patients must also have a medically appropriate diagnosis and be a US citizen or legal resident. |
| Who Can Apply
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Anyone interested can call to have an application faxed or mailed and it can also be downloaded. |
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Required
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The doctor must complete and sign a portion of the application. The patient must also complete and sign a portion of the application and attach required documents. |
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Supply
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Up to one month supply |
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Ship To
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Doctor's office |
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Note
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|
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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.
|
| Miacalcin Injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| (Requires Acrobat Reader)
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