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Equetro Patient Assistance Program
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119 Cherry Hill Road, Suite 310
Parsippany, NJ 07054
Phone
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(866)982-5438
Fax:
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Eligibility
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The patient must have no prescription coverage, be at or below 200% of the Federal Poverty Level and be a US citizen. |
| Who Can Apply
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Anyone requesting assistance can call to have an application faxed or mailed. An application can also be downloaded. |
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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. |
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Supply
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Up to 3 months supply |
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Ship To
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Doctor's office |
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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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| Equetro Extended-Release Capsules |
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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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