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Gate Patient Assistance Program
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OpenGATE MedAssist Program
1090 Horsham Rd
North Wales, PA 19454
Phone
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(800) 292-4283
Ext 3405
Fax:
(215) 653-0839
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Eligibility
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Patients must not be eligible for other sources of drug coverage and must be deemed financially eligible based on company guidelines. |
| Who Can Apply
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Physician's office must call on patient's behalf. |
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Required
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Signed and completed application, patient proof of income and a prescription for a 90 day supply of medication with up to 3 refills are required. |
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Supply
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3 month supply |
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Ship To
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Physician's office. |
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Note
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Patient must re-apply after one year. |
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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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| Galzin (zinc acetate) |
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
:
(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.
Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Note: All new enrollment is now done electronically or over the phone. Contact program for details. |
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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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| Galzin (zinc acetate) |
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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 |
(Requires Acrobat Reader) 
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TEVACares Foundation Patient Assistance Program
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PO Box 52028
Phoenix, AZ 85072
Phone
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877-237-4881
Fax:
877-438-4404
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Eligibility
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Patients must have no prescription coverage for the needed medication, including Medicare Part D. Income requirements for this program are based on the Federal Poverty Level. Patients must be a citizen or US resident. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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Ship To
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Doctor's office or patient's home |
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Note
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The CephalonCares Foundation Patient Assistance Program for Fentora, Gabitril, Nuvigil and Tev-Tropin and the TEVA Assistance Program are now known as the TEVA Cares Foundation Patient Assistance Program.
Contact program for Spanish 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.
|
| Galzin (zinc acetate) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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