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Patient Assistance Information

 
 
 
Prialt Navigator Reimbursement and Access Program


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Phone : 855-774-2581
Fax: 855-774-2583
Eligibility
> The Prialt Navigator Reimbursement and Access Program is intended for patient that are uninsured or are underinsured. Medicare Part D patients are not eligible. Income requirements for this program have not been disclosed. Patients must be a US resident. Diagnosis and medical criteria have not been disclosed for this program.
Who Can Apply
> Doctor or doctor's office must call or download the application from the link below.
Required
> Application must be completed and signed by the doctor and the patient. Insurance information must be attached. The doctor will be notified within 2-3 days. The doctor must contact the company for refills. A new application and documentation are required every year.
Supply
> Up to a 90 day supply.
Ship To
> Medication will be shipped to the doctor's office.
Note
> Resources for HEALTHCARE PROFESSIONAL ONLY. The prescriber must enroll in the Navigator Program before enrolling patients.
 
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.
 
Prialt injectable; intrathecal
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader