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Patient Assistance Information

 
 
 
Photofrin Patient Assistance Program

2730 S. Edmonds Lane, Suite 300
Lewisville, TX 75067
Phone : 855-215-2720
Fax: 855-314-3943
Eligibility
> This program provides brand name medications at no or low cost to patients with no insurance coverage for the needed medication. Medicare Part D recipients are not eligible. Patients must be at or below 200% of the federal poverty level, must have a medically appropriate condition/diagnosis and be a us citizen or legal entrant.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or it can be downloaded.
Required
> Patients must complete a section of the application, sign and attach proof of income. Doctors must also complete and sign a section. The application can then be faxed or mailed.
Supply
> Not specified
Ship To
> Not specified
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.
 
Photofrin injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader