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Patient Assistance Information

 
2 Programs for Ravicti liquid
 
 
Good Days Program

6900 dallas Parkway
Suite 200
Plano, TX 75024
Phone : (877)968-7233
Fax: (214)570-3621
Eligibility
> Insurance requirements not specified, this includes Medicare PartD. Income requirements for this program have not been disclosed. US residency requirements not specified.
Who Can Apply
> Call to have application faxed, mailed, download from website or apply online. Return application via fax, mail or submit online. Patient and/or Doctor are notified of decision.
Required
> Diagnosis/Medical Criteria not specified. Doctor gives prescription to patient. Patient must complete application, sign and attach required documents.
Supply
> Refill process and limit not specified. Must re-enroll at the end of every calendar year.
Ship To
> Shipping location not specified.
Note
> Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
 
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.
 
Ravicti liquid
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Good Days Program
(Requires Acrobat Reader
 
 
Horizon UCD Support Services


,
Phone : 855-823-7878
Fax: 877-695-8304
Eligibility
> The Horizon UCD Support Services program is for patients that have no prescription coverage, have reached a cap, or cannot afford the co-payment. Patients with Medicare Part D are eligible if the medication is not covered by their plan. The patient must be a resident of the US. Patients must have a Urea Cycle Disorder (UCD).
Who Can Apply
> Patients and doctors can apply by obtaining an application by phone or by downloading from the link below.
Required
> The application must be completed and signed by the physician and patient. A copy of the patients insurance information must be attached.
Supply
> Supply varies.
Ship To
> Medication is shipped to the patient's home and patient will contact the pharmacy for re-fills.
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.
 
Ravicti liquid
 
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