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Patient Assistance Information

 
1 Program for Cyramza injection
 
 
PatientOne Oncology

PO Box 4280
Gaithersburg, MD 20885
Phone : (866)472-8663 Ext opt 2
Fax: (877)366-0585
Eligibility
> This program is intended for patients that are uninsured or are underinsured for needed medication. Medicare part D eligibility not specified. Income must be at or below 500% of FPL. Must be US resident.
Who Can Apply
> Call for application to be faxed or download from website. Doctor must complete application and sign. Patient must complete application, sign, and attach copy of income. Healthcare Provider will be notified via fax of decision.
Required
> Must be used for on-label diagnosis
Supply
> Amount/supply varies. Doctor/Doctor's office must complete replacement form for refills. Refill limit is not specified. New application must be completed every 12 months.
Ship To
> Medication will be shipped to Doctor's office.
Note
> The patient and physician must submit information to PatientOne for a benefits investigation before application will be given for the assistance program. For underinsured patients program helps connect patients with programs that can help them cover the cost of copayments and deductibles. Patients who do not have prescription insurance are reviewed for eligibility into the PatientOne patient Lilly assistance program. Certification of Brand Name Drug Usage Form only needs to be completed for those seeking assistance for Gemzar.
 
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.
 
Cyramza injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form PatientOne Oncology
(Requires Acrobat Reader