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Patient Assistance Information

 
3 Programs for Gabitril (tiagabine hydrochloride)
 
 
Cephalon Patient Assistance Program

Gabitril Patient Assistance Program c/o InTeleCenter
P.O. Box 4280
Gaithersburg, MD 20885-4280
Phone : (866) 209-7589
Fax: (866) 209-7596
Eligibility
> Eligibiltiy is based on income, insurance coverage and diagnosis.
Who Can Apply
> Physician's office only
Required
> Proof of income is required
Supply
> Coupon for 90 day supply
Ship To
> Coupon mailed to patient's home and confirmation letter sent to physician
Note
>
 
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.
 
Gabitril (tiagabine hydrochloride)
 
 
 
Gabitril Patient Assistance Program

c/o InTeleCenter
PO Box 4280
Gaithersburg, MD 20885-4280
Phone : 866-209-7589
Fax: 866-209-7596
Eligibility
> 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
> The doctor/doctor's office must call for a prescreening.
Required
> 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.
Supply
> A coupon for 90-day supply
Ship To
>
Note
> The doctor/doctor's office must call for a prescreening.
 
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.
 
Gabitril (tiagabine hydrochloride)
 
 
 
TEVACares Foundation Patient Assistance Program

PO Box 52028
Phoenix, AZ 85072
Phone : 877-237-4881
Fax: 877-438-4404
Eligibility
> 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
> Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded.
Required
> Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income.
Supply
> Varies
Ship To
> Doctor's office or patient's home
Note
> 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.
 
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.
 
Gabitril (tiagabine hydrochloride)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader