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AccessCubicin Program
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PO Box 4280
Gaithersburg, MD 20897
Phone
:
844-282-4246
Fax:
866-428-2478
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Eligibility
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This program provides brand name medications at no or low cost. Patients must be uninsured. Medicare Part D recipients are not eligible. Income requirements for this program have not been disclosed. Medication must medically necessary as determined by a doctor. Patient must be a US resident. |
| Who Can Apply
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Anyone interested can call to have an application faxed or download one. |
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Required
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Doctors must complete the application, sign and attach required documents. Patient must complete and sign their section and then the application can be faxed. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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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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| Cubicin Injection |
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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 |
| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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Cubicin Reimbursement Hotline
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Not Applicable
,
Phone
:
866-793-2786
Ext OPT 2
Fax:
866-428-2478
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Eligibility
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This program is based on guidelines that are not disclosed. This is a product replacement program. |
| Who Can Apply
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The doctor, patient, social worker or patient advocate must call for a prescreening. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section and sign the application. |
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Supply
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Ship To
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Hospital, Doctor's office or specific site (clinic, hospital, infusion site etc.) |
|
Note
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The doctor, patient, social worker or patient advocate must call for a prescreening. |
| |
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.
|
| Cubicin Injection |
| |
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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|