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AccessZerbaxa Program
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Phone
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844-282-4782
Fax:
844-282-4783
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Eligibility
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This program provides brand name medications at no or low cost. Patients must be uninsured. Patients with Medicare Part D are not eligible. Income requirements for this program have not been disclosed. Patients must be a US resident. |
| Who Can Apply
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Doctor or doctor's office can call to have an application faxed or can download one. |
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Required
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Doctors must complete and sign the application. The patient must complete their section, sign and then the application can be faxed. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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This program only offers product replacement for product provided to patients who are completely uninsured if they meet other eligibility criteria. A product replacement form is required. |
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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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| Zerbaxa injection |
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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 |
| Download printable Form |
(Requires Acrobat Reader) 
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