| |
Trisenox Drug Replacement Program
|
Address: N/A
,
Phone
:
(866) 261-7730
Fax:
(888) 891-4924
|
|
Eligibility
|
| > |
The patient must have no prescription coverage for the medication and meet income guidelines that are not disclosed. The patient must also be a US citizen being treated by a US doctor. A negative decision can be appealed.
|
| Who Can Apply
|
| > |
The doctor/doctor's office should call for an application. The application will be faxed out. The completed application must be faxed back. |
|
Required
|
| > |
The doctor must fill out a section and sign the application. The patient must fill out a section and sign the application.
|
|
Supply
|
| > |
n/a |
|
Ship To
|
| > |
Doctor's office |
|
Note
|
| > |
Once a year the application process must be repeated. |
| |
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.
|
| Trisenox (arsenic trioxide) |
| |
| |
|
|
| |
Trisenox Patient Assistance Program
|
,
Phone
:
866 261-7730
Fax:
888-891-4924
|
|
Eligibility
|
| > |
The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be a US citizen being treated by a US doctor. |
| Who Can Apply
|
| > |
The doctor/doctor's office should call for an application. |
|
Required
|
| > |
The doctor must fill out a section and sign the application.The patient must fill out a section and sign the application. |
|
Supply
|
| > |
|
|
Ship To
|
| > |
Doctor's office |
|
Note
|
| > |
The doctor/doctor's office should call for an 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.
|
| Trisenox (arsenic trioxide) |
| |
| |
|
|