Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
3 Programs for Myobloc (botulinum toxin type B)
 
 
MYOBLOC Patient Assistance Program


,
Phone : 888-461-2255 Ext 3
Fax: 888-343-3275
Eligibility
> Patients must be uninsured, be at or below 350% of the Federal Poverty Level, have Cervical Dystonia and be a US citizen.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. It can also be completed online or downloaded.
Required
> Doctors must complete a section and sign. Patients must complete a section, sign, attach proof of income and attach other requested documentation.
Supply
> Not specified
Ship To
> Not specified
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.
 
Myobloc (botulinum toxin type B)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
MYOBLOC Reimbursement Support Program


,
Phone : 888-461-2255 Ext 3
Fax: 888-343-3275
Eligibility
> Patient insurance requirements have not been specified and income requirements have not been disclosed. Patients must have a medically appropriate condition/diagnosis and be a US citizen.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. Applications can also be completed online or downloaded.
Required
> Doctors and patients must both complete a section of the application and sign.
Supply
> Not specified
Ship To
> Not specified
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.
 
Myobloc (botulinum toxin type B)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Solstice Co-Pay Assistance Program

4700 Millenia Blvd., Suite 310
Orlando, FL 32839
Phone : 888-461-2255 Ext 3
Fax: 888-343-3275
Eligibility
> Patients must not have public insurance but may have private insurance. Patients must be at or below 350% of the Federal Poverty Level and have Cervical Dystonia. Massachusetts residents are not eligible.
Who Can Apply
> Doctor of hospital must call to have an application faxed or mailed.
Required
> Doctor starts the process by submitting an insurance verification request online or via fax. Patients must complete a section of the application, sign, attach proof of income and attach any insurance information.
Supply
> Not applicable
Ship To
> Not applicable
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.
 
Myobloc (botulinum toxin type B)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader