Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
 
 
Xeomin Patient Support Program

PO Box 4280
Gaithersburg, MD 20885
Phone : 888-493-6646
Fax: 866-471-3005
Eligibility
> This program provides brand name medications at no or low cost for patients that are uninsured or underinsured. Patient that are Medicare Part D eligible are not eligible for this program. Income requirements for this program have not been disclosed. Patients must have an FDA-approved or authorized compendia listing and must be a US citizen or legal resident.
Who Can Apply
> Anyone interested can obtain an application by calling or downloading.
Required
> Doctors must complete and sign the application. Patients must also complete and sign the application, as well as attach proof of income and any insurance information. The application can be returned by fax or mail.
Supply
> Varies
Ship To
> Doctor's office
Note
> Contact program for Spanish application.
 
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.
 
Xeomin injection