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Cephalon Patient Assistance Program
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Gabitril Patient Assistance Program c/o InTeleCenter
P.O. Box 4280
Gaithersburg, MD 20885-4280
Phone
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(866) 209-7589
Fax:
(866) 209-7596
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Eligibility
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Eligibiltiy is based on income, insurance coverage and diagnosis. |
| Who Can Apply
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Physician's office only |
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Required
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Proof of income is required |
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Supply
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Coupon for 90 day supply |
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Ship To
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Coupon mailed to patient's home and confirmation letter sent to physician |
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Note
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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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| Gabitril (tiagabine hydrochloride) |
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Gabitril Patient Assistance Program
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c/o InTeleCenter
PO Box 4280
Gaithersburg, MD 20885-4280
Phone
:
866-209-7589
Fax:
866-209-7596
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Eligibility
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The patient must be uninsured and have an income at or below 200% of the Federal Poverty Level. The patient must also be taking the medication for an on-label diagnosis.The patient must also be a US resident. |
| Who Can Apply
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The doctor/doctor's office must call for a prescreening. |
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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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A coupon for 90-day supply |
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Ship To
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Note
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The doctor/doctor's office must call for a prescreening. |
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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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| Gabitril (tiagabine hydrochloride) |
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TEVACares Foundation Patient Assistance Program
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PO Box 52028
Phoenix, AZ 85072
Phone
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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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| Gabitril (tiagabine hydrochloride) |
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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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