| |
Xeomin Patient Co-Pay Program
|
PO Box 4280
Gaithersburg, MD 20898
Phone
:
888-493-6646
Fax:
866-471-3005
|
|
Eligibility
|
| > |
This is a copay assistance program for patients that have private insurance. Patients may not have Medicare Part D or have public insurance. There are no income limits for this program. Massachusetts residents are not eligible. |
| Who Can Apply
|
| > |
Anyone interested can call for an application. |
|
Required
|
| > |
Doctors must complete and sign the application. Patients must complete, sign and attach insurance information to the application and fax or mail it in. |
|
Supply
|
| > |
N/A |
|
Ship To
|
| > |
N/A |
|
Note
|
| > |
This is a reimbursement program. The patient pays for medication and procedures and then is sent a Mastercard with the reimbursement amount which can be used anywhere Mastercard is accepted.
Contact program for Spanish application. |
| |
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.
|
| Xeomin injection |
| |
| |
|
|
| |
Xeomin Patient Support Program
|
PO Box 4280
Gaithersburg, MD 20885
Phone
:
888-493-6646
Fax:
866-471-3005
|
|
Eligibility
|
| > |
This program provides brand name medications at no or low cost for patients that are uninsured or underinsured. Patient that are Medicare Part D eligible are not eligible for this program. Income requirements for this program have not been disclosed. Patients must have an FDA-approved or authorized compendia listing and must be a US citizen or legal resident. |
| Who Can Apply
|
| > |
Anyone interested can obtain an application by calling or downloading. |
|
Required
|
| > |
Doctors must complete and sign the application. Patients must also complete and sign the application, as well as attach proof of income and any insurance information. The application can be returned by fax or mail. |
|
Supply
|
| > |
Varies |
|
Ship To
|
| > |
Doctor's office |
|
Note
|
| > |
Contact program for Spanish application. |
| |
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.
|
| Xeomin injection |
| |
| |
|
|