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Patient Assistance Information

 
 
 
ProThelial Sample Program

1768 Storrs Road
Mansfield, CT 06268
Phone : (860)477-0961
Fax: (860)477-0962
Eligibility
> This program is for Healthcare Professionals Only. Patients insurance status and income will be considered on a case by case basis. Patients with Medicare Part D will be considered on an exception basis. Patient's must have a medically appropriate diagnosis. Residency requirements have not been specified for this program.
Who Can Apply
> Healthcare providers can call to have an application faxed or download the application.
Required
> Doctors must complete and sign a section of the application. Patients must complete and sign a section of the application.
Supply
> Amount requested is sent
Ship To
> Doctor's office or patient's home
Note
> ProThelialâ„¢ is indicated for the management (treatment and prevention) of oral mucositis of any cause.
 
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.
 
Prothelial paste
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader