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Patient Assistance Information

 
2 Programs for TARGRETIN® (bexarotene) Gel
 
 
Diplomat's Co-Pay Assistance Navigator Program

Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone : (877)977-9118 Ext 89864
Fax: (810)282-0176
Eligibility
> Insurance determined case by case. Medicare Part D patients are eligible for this program. Income requirements determined case by case. Must be a US resident. Must have medically appropriate condition/diagnosis.
Who Can Apply
> Patient or Doctor may call to receive application via fax or mail. May also complete application online. Application is to be mailed or faxed back to company.
Required
> Doctor's action will be discussed with patient and Doctor after request is received. Patient must complete application, sign and provide annual income information. Proof of income may be requested by program at any time. Patient and/or Doctor are notified of decision within 1-2 business days.
Supply
> Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case.
Ship To
> Once approved medication is shipped to Patient's home within 2 business days.
Note
> Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie
 
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.
 
TARGRETIN® (bexarotene) Gel
 
 
 
Valeant Patient Assistance Program

PO Box 429303
Cincinnati, OH 45242-9303
Phone : 1-833-862-VPAP (1-833-862-8727)
Fax: 1-866-777-5705
Eligibility
> The patient must be a legal US resident. The patient must be treated as outpatient and have a valid prescription from a licensed U.S. healthcare Professional for a product that is included in the Valeant PAP. The patient must be uninsured; be denied coverage for Valeant product by their commercial insurance provider and have exhausted all appeal options; or not have coverage for the Valeant product requested through government health insurance, (i.e., Medicare Part B, Medicare Part D, Medicaid, Medigap, VA, DoD, TRICARE or other federal or state pharmacy assistance programs). Income criteria varies by product. To determine your eligibility to apply, or to view our full Eligibility Requirements please visit our website at ValeantPAP.com.
Who Can Apply
> Patients in financial need who don’t have health insurance coverage for certain Valeant prescription products.
Required
> Complete the Patient Information and Insurance Information Sections on page 1.
Read and sign the Patient Authorization and Certification on page 2.
Have your prescriber complete pages 3 and 4 and sign Prescriber Certification on page 4.
Supply
> If applicable, attach a copy of your medical and prescription insurance cards.
Ship To
> Valeant prescription products are shipped to the Patient’s Home or Prescribing Physician’s Office. Orders for Controlled Substances and products administered by the physician will be shipped to comply with all state rules and regulations pertaining to how these items can be transported.
Note
> To determine your eligibility to apply, or to view our full Eligibility Requirements please visit our website at ValeantPAP.com. If you have questions about your eligibility or would like to speak with us about alternate funding options, please call the Valeant PAP at 833-862-VPAP (833-862-8727), 8 AM to 5 PM ET.
 
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.
 
TARGRETIN® (bexarotene) Gel
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader