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Patient Assistance Information

 
 
 
Nascobal Patient Assistance Program

1267 Professional Parkway
Gainsville, GA 30507
Phone : (800)589-0841
Fax: (855)828-1491
Eligibility
> 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
> 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.
Required
> Doctor must complete and sign application. Patient must complete application, sign and attach required documents.
Supply
> 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.
Ship To
> Medication ships to Doctor's office within 2 days.
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.
 
Nascobal spray; nasal
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Nascobal Patient Assistance Program
(Requires Acrobat Reader