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Patient Assistance Information

 
1 Program for Provenge autologous cellular immunotherapy
 
 
PROVENGE Patient Assistance


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Phone : 877-336-3736
Fax: 877-556-3737
Eligibility
> This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Household income at or less than $150,000 & US Resident. Must be used for on-label diagnosis.
Who Can Apply
> The Doctor should call for an application to be mailed or faxed or download it from the website. Application must be returned via fax.
Required
> Doctors and patients must complete and sign the application.
Supply
> Amount requested per cycle is sent. No refills, 3 infusion limit. This is a one time program.
Ship To
> Medication sent to Doctor's office or infusion site. Delivery time not specified.
Note
> Insurance benefits, claims assistance,/or other reimbursement help is offered.
 
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.
 
Provenge autologous cellular immunotherapy
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form PROVENGE Patient Assistance
(Requires Acrobat Reader