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Gate Patient Assistance Program
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OpenGATE MedAssist Program
1090 Horsham Rd
North Wales, PA 19454
Phone
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(800) 292-4283
Ext 3405
Fax:
(215) 653-0839
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Eligibility
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Patients must not be eligible for other sources of drug coverage and must be deemed financially eligible based on company guidelines. |
| Who Can Apply
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Physician's office must call on patient's behalf. |
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Required
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Signed and completed application, patient proof of income and a prescription for a 90 day supply of medication with up to 3 refills are required. |
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Supply
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3 month supply |
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Ship To
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Physician's office. |
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Note
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Patient must re-apply after one year. |
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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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| Orap (pimozide) |
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TEVACares Foundation Patient Assistance Program
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PO Box 52028
Phoenix, AZ 85072
Phone
:
877-237-4881
Fax:
877-438-4404
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Eligibility
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Patients must have no prescription coverage for the needed medication, including Medicare Part D. Income requirements for this program are based on the Federal Poverty Level. Patients must be a citizen or US resident. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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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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The CephalonCares Foundation Patient Assistance Program for Fentora, Gabitril, Nuvigil and Tev-Tropin and the TEVA Assistance Program are now known as the TEVA Cares Foundation Patient Assistance Program.
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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| Orap (pimozide) |
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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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