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Patient Assistance Information

Mylan Clozapine Patient Assistance Program

781 Chestnut Ridge Rd
Morgantown, WV 26554
Phone : (800)395-3376
Fax: (304)554-4713
> The patient must have no prescription coverage for any medications and be financially unable to afford the medication. Patient must be at or below 200% federal poverty level. The patient must also have a medically appropriate diagnosis and be a citizen or legal resident.
Who Can Apply
> Anyone interested can call for an application and it can be faxed or mailed to them.
> The doctor must fill out a section, sign the application and attach a prescription.The patient must complete a section, sign and provide proof of income and proof of lack in insurance.
> Up to a 90-day supply
Ship To
> Pharmacy
> There are two steps and two sets of paperwork for this program. The first step is to register the patient, which is required for any patient taking Clozapine, regardless of insurance or financial situations. Call 800-843-9915 to register. This is a two-page form that the patient, physician and pharmacist must fill out. Contact program for Spanish 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.
Clozapine Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form Application Form
(Requires Acrobat Reader