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Betaseron Patient Assistance Program
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PO Box 221349
Charlotte, NC 28222-1349
Phone
:
877-836-5724
Fax:
877-744-5615
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Eligibility
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The patient must meet insurance and financial guidelines that are not disclosed. The patient must also have MS.The patient must also be a US resident. |
| Who Can Apply
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The doctor or patient can call to request an application. |
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Required
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The doctor needs to complete an application, sign it and attach a prescription.The patient needs to complete an application, sign it, and attach proof of income and other requested documentation. |
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Supply
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A 90-day supply |
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Ship To
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Patient's home |
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Note
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The doctor or patient can call to request an 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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| Betaseron (interferon beta-1b) |
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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 Application Form |
(Requires Acrobat Reader) 
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The Betaseron Foundation
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The Betaseron Foundation
PO Box 221349
Charlotte, NC 28222-1349
Phone
:
(800) 948-5777
Fax:
(877) 744-5615
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Eligibility
|
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Patients must have a confirmed diagnosis of multiple sclerosis and be U.S. residents. |
| Who Can Apply
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Anyone may call to initiate application process.
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Required
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Patients and their prescribing physicians must submit a completed application, and income verification is required. A copy of the most recent federal tax return is preferred, with verification of any Social Security benefits received. |
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Supply
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As indicated by physician. |
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Ship To
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Physician's office. |
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Note
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Program participants are required to pay a program participation fee for the Betaseron provided through the foundation. Eligibility for continuation in the program will be verified periodically, and all applications must be renewed annually. |
| |
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.
|
| Betaseron (interferon beta-1b) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
| (Requires Acrobat Reader)
|
| |
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