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Photofrin Patient Assistance Program
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2730 S. Edmonds Lane, Suite 300
Lewisville, TX 75067
Phone
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855-215-2720
Fax:
855-314-3943
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Eligibility
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This program provides brand name medications at no or low cost to patients with no insurance coverage for the needed medication. Medicare Part D recipients are not eligible. Patients must be at or below 200% of the federal poverty level, must have a medically appropriate condition/diagnosis and be a us citizen or legal entrant. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or it can be downloaded. |
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Required
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Patients must complete a section of the application, sign and attach proof of income. Doctors must also complete and sign a section. The application can then be faxed or mailed. |
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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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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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| Photofrin 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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