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Arestin Rx Access Co-Pay
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Phone
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855-684-7481
Fax:
855-630-9783
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Eligibility
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This program is for Healthcare Professionals Only.
Patients must have no insurance. Patients must be 18 years old or older and must be treated by a US doctor. |
| Who Can Apply
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Healthcare providers can call to have an application faxed or download one. |
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Required
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Doctors must enroll in the program, complete the form and obtain patient consent. Patients must complete a section of the form and sign. The application must then be faxed from the doctor's office. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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Co-Pay Assistance expires 12/31/2016. The offer is only valid for patients with private insurance. |
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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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| Arestin powder; extended release |
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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 |
(Requires Acrobat Reader) 
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