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GLIADEL WAFER Patient Assistance
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PO Box 259
Acworth, GA 30101
Phone
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(866)516-4950
Ext 4
Fax:
(866)468-2420
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Eligibility
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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
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Patients can apply for this program by fax or mail. |
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Required
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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. |
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Supply
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1 box (includes 8 wafers) |
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Ship To
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The product is shipped to the hospital. |
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Note
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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. |
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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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| Gliadel wafer: polifeprosan 20 with carmustine implant |
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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 Arbor Pharmaceuticals Patient Assistance Program for Gliadel |
(Requires Acrobat Reader) 
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