Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
2 Programs for Panretin Gel
 
 
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.
 
Panretin Gel
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Rx Outreach Medications

PO Box 66536
St Louis, MO 63166
Phone : (888)796-1234
Fax: (800)875-6591
Eligibility
> Patients with insurance, including Medicare Part D, are eligible. Patients must be at or below 300% of the federal poverty level and reside in the US.
Who Can Apply
> Patients or healthcare providers can call to have an application mailed or faxed. It can also be downloaded.
Required
> Patients must complete a section and sign. Doctors must provide the patient with a prescription. The application can then be faxed and the prescription can be sent by E-Prescribe.
Supply
> Varies
Ship To
> Doctor's office or patient's home
Note
> Some medications are available for a fee of $20 for up to a 180 day supply. Check the Rx Outreach website for the exact price and most current medication list. Contact Program for Spanish Application(s)/Form(s).
 
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.
 
Panretin Gel
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader