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Patient Assistance Information

 
1 Program for Mirvaso gel; topical
 
 
Galderma Laboratories Patient Assistance Program

2730 S. Edmonds Lane
Lewisville, TX 75067
Phone : (855)431-3737
Fax: (855)431-3738
Eligibility
> The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below 200% of the Federal Poverty Level. Must be US resident and be treated by US doctor.
Who Can Apply
> Call for fax or mailed application or download from website. Return application via email, fax or mail. Patient will be notified in writing within 2-4 business days.
Required
> Medically appropriate condition/diagnosis required. The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income.
Supply
> Up to 30day supply. Patient must contact company for refills. Refill limit up to 2yrs. Must re-enroll at the end of each calendar year.
Ship To
> Shipped to patient's home within 5-7 business days.
Note
> Anyone can write the company to request an 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.
 
Mirvaso gel; topica
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Galderma Laboratories Patient Assistance Program
(Requires Acrobat Reader