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Torisel Reimbursement Support and Patient Assistance Program
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PO Box 220907
Charlotte, NC 28222
Phone
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866-993-8466
Fax:
866-993-8411
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Eligibility
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The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor. |
Who Can Apply
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The doctor/doctor's office should call for an application. |
Required
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The doctor must fill out a section and sign the application.The patient must fill out a section of the enrollment form and sign it. |
Supply
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Ship To
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Doctor's office |
Note
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The doctor/doctor's office should call for 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. |
Neumega |
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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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Wyeth Oncology Reimbursement Program
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Wyeth Oncology Reimbursement Program
Lash Group San Bruno, CA 94066
Phone
:
(888) 638-6342
Fax:
(866) 836-0819
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Eligibility
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The patient must not have prescription coverage for the medication and have an income at or below 325% od the US Povertly Level. The patient must be under treatment from a US doctor. |
Who Can Apply
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The doctor/doctor's office should call for an application. The application will be faxed out. The completed application must be mailed back. |
Required
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The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number. The patient must fill out a section, sign the application and attach proof of income.
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Supply
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Up to a 90-day supply is sent to the doctor's office. The doctor/doctor's office must contact the company to arrange refills. Once a year a new application with documentation is needed. |
Ship To
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The medication is shipped to the doctor within 10 business days. Both the patient and doctor are notified in writing of acceptance or denial.
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Note
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The company also provides drug replacement if the insurance is denied and it is for an FDA-approved diagnosis. |
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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. |
Neumega |
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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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