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Patient Assistance Information

 
1 Program for Gliadel wafer: polifeprosan 20 with carmustine implant
 
 
GLIADEL WAFER Patient Assistance

PO Box 259
Acworth, GA 30101
Phone : (866)516-4950 Ext 4
Fax: (866)468-2420
Eligibility
> The patient must have no insurance and be at or below 200% of the Federal Poverty Level. The patient must have a medically appropriate condition/diagnosis and must be a citizen of the US and its Territories and be under the care of a US physician.
Who Can Apply
> Patients can apply for this program by fax or mail.
Required
> Healthcare Providers must complete and sign a section of the application and attach a prescription. Patients must complete and sign a section, attach proof of income and any insurance information.
Supply
> 1 box (includes 8 wafers)
Ship To
> The product is shipped to the hospital.
Note
> Application decision will be made within 2 weeks. The product is delivered within 2 to 4 business days. Patients must contact the company for refills.
 
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.
 
Gliadel wafer: polifeprosan 20 with carmustine implant
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Arbor Pharmaceuticals Patient Assistance Program for Gliadel
(Requires Acrobat Reader