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GTX Patient Assistance Program
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PO Box 8203
Somerville, NJ 08876
Phone
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866-325-8231
Fax:
866-694-2546
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below 225% of the Federal Poverty Level. The patient must also be a US resident. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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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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Doctor's office |
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Note
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With the patient's permission, anyone concerned can call for an 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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| Fareston 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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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
:
(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
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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.
|
| Fareston Tablets |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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Patient Rx Solutions Program - Fareston
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Fareston Patient Assistance Program PO Box 325
Florham Park, NJ 07932
Phone
:
866-325-8231
Fax:
866-694-2546
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Eligibility
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his program provides brand name medications at no or low cost to commercial and Medicare Part D insurance recipients that have no insurance coverage for the needed medication. Patients must be at or below 300% of the federal poverty level and must be a citizen or US resident. |
| Who Can Apply
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The doctor or doctor's office must call. |
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Required
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The doctor or doctor's office must call. for a prescreening and an application will be sent to the doctor's office. The doctor must complete a section of the application, sign and attach a prescription. The patient must complete a section of the application, sign and attach proof of income. The application must then be faxed or mailed. |
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Supply
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Up to 12 months |
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Ship To
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Doctor's office |
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Note
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This Company also offers a Reimbursement Program.
FARESTON Copay Assistance Card Program: Savings of up to $150 per month toward each prescription (after paying the first $20) for up to 12 prescriptions per year for eligible patients.
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.
|
| Fareston Tablets |
| |
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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