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Patient Assistance Information

 
3 Programs for EstroGel
 
 
Ascend Therapeutics Patient Assistance Program

PO Box 2092
Morrisville, PA 19067-9608
Phone : 877-204-1013
Fax:
Eligibility
> This program is based on guidelines that are not disclosed. The patient must also be a US resident.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
Supply
> A voucher is sent to the patient's home.
Ship To
> Patient's home
Note
> Anyone requesting assistance can call to request a faxed application or download it from the website.
 
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.
 
EstroGel
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> 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
> Patients or healthcare providers can complete the application online or by phone.
Required
> 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.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *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.
 
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.
 
EstroGel
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Solvay Pharmaceuticals Patient Assistance Program

C/O Express Scripts Speciality Distribution Svc.
PO Box 66550
St. Louis, MO 63166-6550
Phone : 800-256-8918
Fax: 800-276-9901
Eligibility
> The patient must have no prescription insurance. meet income guidelines that are not disclosed. The patient must also be a US resident. If a patient did not enroll in Medicare Part D, then s/he may still be eligible for this program and should apply. If a patient has Part D and has been denied coverage for Estrates, they may be considered by this program.
Who Can Apply
> With the patient's permission, anyone concerned can call for an application.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
Supply
> Up to a 90-day supply
Ship To
> Doctor's office
Note
> The patient or doctor must contact the company for refills. Once a year a new application with financial documentation is needed.
 
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.
 
EstroGel
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader