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PROVENGE Patient Assistance
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Phone
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877-336-3736
Fax:
877-556-3737
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Eligibility
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This program is intended for patients that are uninsured. Medicare Part D patients are not eligible for this program. Household income at or less than $150,000 & US Resident. Must be used for on-label diagnosis. |
| Who Can Apply
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The Doctor should call for an application to be mailed or faxed or download it from the website. Application must be returned via fax. |
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Required
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Doctors and patients must complete and sign the application. |
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Supply
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Amount requested per cycle is sent. No refills, 3 infusion limit. This is a one time program. |
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Ship To
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Medication sent to Doctor's office or infusion site. Delivery time not specified. |
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Note
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Insurance benefits, claims assistance,/or other reimbursement help is offered. |
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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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| Provenge autologous cellular immunotherapy |
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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 PROVENGE Patient Assistance |
(Requires Acrobat Reader) 
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