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Patient Assistance Information

 
2 Programs for Mylotarg
 
 
Torisel Reimbursement Support and Patient Assistance Program

PO Box 220907
Charlotte, NC 28222
Phone : 866-993-8466
Fax: 866-993-8411
Eligibility
> The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor.
Who Can Apply
> The doctor/doctor's office should call for an application.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section of the enrollment form and sign it.
Supply
>
Ship To
> Doctor's office
Note
> The doctor/doctor's office should call for an 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.
 
Mylotarg
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Wyeth Oncology Reimbursement Program

Wyeth Oncology Reimbursement Program
Lash Group
San Bruno, CA 94066
Phone : (888) 638-6342
Fax: (866) 836-0819
Eligibility
> The patient must not have prescription coverage for the medication and have an income at or below 325% od the US Povertly Level. The patient must be under treatment from a US doctor.
Who Can Apply
> The doctor/doctor's office should call for an application. The application will be faxed out. The completed application must be mailed back.
Required
> The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number. The patient must fill out a section, sign the application and attach proof of income.
Supply
> Up to a 90-day supply is sent to the doctor's office. The doctor/doctor's office must contact the company to arrange refills. Once a year a new application with documentation is needed.
Ship To
> The medication is shipped to the doctor within 10 business days. Both the patient and doctor are notified in writing of acceptance or denial.
Note
> The company also provides drug replacement if the insurance is denied and it is for an FDA-approved diagnosis.
 
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.
 
Mylotarg
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader