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Patient Assistance Information

 
 
 
AccessZerbaxa Program


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Phone : 844-282-4782
Fax: 844-282-4783
Eligibility
> This program provides brand name medications at no or low cost. Patients must be uninsured. Patients with Medicare Part D are not eligible. Income requirements for this program have not been disclosed. Patients must be a US resident.
Who Can Apply
> Doctor or doctor's office can call to have an application faxed or can download one.
Required
> Doctors must complete and sign the application. The patient must complete their section, sign and then the application can be faxed.
Supply
> Not specified
Ship To
> Not specified
Note
> This program only offers product replacement for product provided to patients who are completely uninsured if they meet other eligibility criteria. A product replacement form is required.
 
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.
 
Zerbaxa injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader