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Patient Assistance Information

 
 
 
Xelsource Answers and Support for Xeljanz

2730 S. Edmonds Lane, Suite 300,
Lewisville, TX 75067
Phone : 855-493-5526
Fax: 866-297-3471
Eligibility
> Patients must be uninsured or underinsured. Medicare Part D recipients are also eligible. Income requirements for this program vary. Patients must live in the US.
Who Can Apply
> Patients or healthcare professionals can call to have an application mailed or download the application.
Required
> Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income.
Supply
> Varies
Ship To
> Varies
Note
>
 
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.
 
Xeljanz tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader