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Patient Assistance Information

 
 
 
Varizig Patient Assistance Program

PO Box 1041
Morristown, NJ 07962
Phone : (973)656-2626
Fax: (973)644-2361
Eligibility
> This program is intended for Patient's with no prescription coverage this includes Medicare partD. Income is to be at or below 200% of FPL. US residency requirements not specified.
Who Can Apply
> Call to have application faxed, return application via fax or mail. Healthcare provider will be notified of decision within 48hrs.
Required
> Must have medically appropriate condition/diagnosis. Doctor must complete application and sign. Patient must complete application, sign, attach proof of income and insurance information.
Supply
> Amount/supply varies. Doctor/Doctor's office must complete replacement form for refills. 3 month refill limit then a new application must be completed.
Ship To
> Medication will be shipped to Doctor's office, hospital or pharmacy within 3-5 business days.
Note
> No online application.
 
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.
 
Varizig