| |
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)
|
| |
|
|