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Nascobal Patient Assistance Program
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1267 Professional Parkway
Gainsville, GA 30507
Phone
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(800)589-0841
Fax:
(855)828-1491
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Eligibility
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This program is intended for Patients with no prescription insurance coverage, this includes Medicare partD patients. Income must be at or below 200% of FPL and a US resident. Diagnosis/medical criteria not specified. |
| Who Can Apply
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Call for fax or mailed application or download from website. Application must be returned from the prescriber's office via fax or mail. Decision will be communicated within 2-3 days. |
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Required
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Doctor must complete and sign application. Patient must complete application, sign and attach required documents. |
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Supply
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Amount/supply varies. Copy of application with new signatures and new prescription required for refills. Refill limit not specified. Company contacts patient about reapplying after 6 months. |
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Ship To
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Medication ships to Doctor's office within 2 days. |
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Note
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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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| Nascobal spray; nasal |
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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 Nascobal Patient Assistance Program |
(Requires Acrobat Reader) 
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