Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
 
 
Equetro Patient Assistance Program

119 Cherry Hill Road, Suite 310
Parsippany, NJ 07054
Phone : (866)982-5438
Fax:
Eligibility
> The patient must have no prescription coverage, be at or below 200% of the Federal Poverty Level and be a US citizen.
Who Can Apply
> Anyone requesting assistance can call to have an application faxed or mailed. An application can also be downloaded.
Required
> The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application and attach proof of income.
Supply
> Up to 3 months supply
Ship To
> Doctor's office
Note
>
 
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.
 
Equetro Extended-Release Capsules
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader