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Patient Assistance Information

 
1 Program for Ontak (denileukin diftitox)
 
 
Ligand Assistance Program

Ligand Assistance Program
PO Box 222197
Charlotte, NC 28222-2197
Phone : (877) 654-4263
Fax: (877) 654-6760
Eligibility
> The patient must have no prescription coverage or have reached his/her cap and meet income guidelines that are not disclosed. This program is handled on a case-by-case basis. Patients in need should contact them.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application. The application can be either faxed or mailed out. The completed application can be faxed or mailed back. Both the patient and doctor are notified in writing of acceptance or denial. The decision is usually made within 48 hours.
Required
> The doctor must fill out a section, sign the application and attach a prescription. The patient must fill out a section and sign the application.
Supply
> 30 Day supply
Ship To
> Physician's office
Note
> The company contacts the doctor to arrange for refills. Each medication has different guidelines for renewal.
 
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.
 
Ontak (denileukin diftitox)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader