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Patient Assistance Information

 
 
 
SP-Cares

PO Box 52122
Phoenix, AZ 85072
Phone : 800-656-9485 Ext OPT 1
Fax: 800-995-9620
Eligibility
> The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level.
Who Can Apply
> Anyone requesting assistance can call to request a faxed application or download it from the website.
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 a 90-day supply
Ship To
> Doctor's office
Note
> Anyone requesting assistance can call to request a faxed application or download it from the website.
 
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.
 
Asmanex Twisthaler Inhalation Powder
Avelox Tablets
Cipro XR Tablets
Diprolene Lotion (betamethasone dipropionate)
Diprolene Ointment (betamethasone dipropionate)
Elocon Cream (mometasone furoate)
Elocon Lotion (mometasone furoate)
Elocon Ointment (mometasone furoate)
Foradil Powder for Inhalation
K-Dur Tablets
Lotrisone Cream
Lotrisone Lotion
Nasonex Nasal Spray
Nitro-Dur Patch
Proventil HFA Inhaler
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Application Form
(Requires Acrobat Reader