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Patient Assistance Information

 
2 Programs for Cubicin Injection
 
 
AccessCubicin Program

PO Box 4280
Gaithersburg, MD 20897
Phone : 844-282-4246
Fax: 866-428-2478
Eligibility
> 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
> Anyone interested can call to have an application faxed or download one.
Required
> Doctors must complete the application, sign and attach required documents. Patient must complete and sign their section and then the application can be faxed.
Supply
> Not specified
Ship To
> Not specified
Note
>
 
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
Download printable Form
Download printable Form
(Requires Acrobat Reader
 
 
Cubicin Reimbursement Hotline

Not Applicable
,
Phone : 866-793-2786 Ext OPT 2
Fax: 866-428-2478
Eligibility
> This program is based on guidelines that are not disclosed. This is a product replacement program.
Who Can Apply
> The doctor, patient, social worker or patient advocate must call for a prescreening.
Required
> The doctor must fill out a section and sign the application.The patient must fill out a section and sign the application.
Supply
>
Ship To
> Hospital, Doctor's office or specific site (clinic, hospital, infusion site etc.)
Note
> 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