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Daraprim Direct Program
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,
Phone
:
844-267-3323
Fax:
877-241-1365
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Eligibility
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Insurance status will be considered on a case by case basis. Patients must meet income requirements that have not been disclosed and have a medically appropriate condition/diagnosis. |
Who Can Apply
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Doctors can call for an application or download one. |
Required
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Patients must inform the doctor that they are in need. Doctors must complete a section of the application, sign and attach required documents. |
Supply
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Not specified |
Ship To
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Not specified |
Note
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Resources for HEALTHCARE PROFESSIONALS ONLY.
This program provides delivery, reimbursement and support services. |
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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. | Daraprim Tablets |
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Printable Application Forms Applications that patients can fill out and bring to their doctor. | Download printable Form | (Requires Acrobat Reader)
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GlaxoSmithKline Bridges to Access Program
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PO Box 29038,Phoenix, AZ 85038-9038
Phoenix, AZ 85038-9038
Phone
:
866-728-4368
Fax:
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level. The patient must also be a US resident. |
Who Can Apply
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The patient advocate can call for an application or start the application process on line. |
Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application, and attach proof of income and any denial letters from insurance companies. |
Supply
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> |
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Ship To
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Patient's home advocate |
Note
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> |
The patient advocate can call for an application or start the application process on line. |
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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. | Daraprim Tablets |
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Orange Card
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Orange Card
,
Phone
:
(888) 672-6436
Fax:
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Eligibility
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Seniors age 65 and older and the disabled enrolled in Medicare with annual income below $30,000 single/$40,000 couple (approximately 300% of poverty) and patient must not have public or private insurance coverage for prescription medicines.
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Who Can Apply
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Patient should call for application. |
Required
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Minimal information is required. |
Supply
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> |
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Ship To
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Note
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Discounts are 25% off the wholesale list price of GlaxoSmithKline outpatient drugs. Participating pharmacies charge card holders no more than a negotiated price. GlaxoSmithKline expects card holders to realize average savings of 30-40% off retail prices.
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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. | Daraprim Tablets |
|
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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