| |
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)
|
| |
|
|