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Prialt Navigator Reimbursement and Access Program
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Phone
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855-774-2581
Fax:
855-774-2583
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Eligibility
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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
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Doctor or doctor's office must call or download the application from the link below. |
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Required
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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. |
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Supply
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Up to a 90 day supply. |
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Ship To
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Medication will be shipped to the doctor's office. |
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Note
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Resources for HEALTHCARE PROFESSIONAL ONLY.
The prescriber must enroll in the Navigator Program before enrolling patients. |
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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.
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| Prialt injectable; intrathecal |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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