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Patient Assistance Information


Phone : 855-888-4004
Fax: 877-773-9411
> Patients with insurance, including Medicare Part D, may apply. Income requirements for this program have not been disclosed. Patients must have a medically appropriate condition/diagnosis and must be a US resident.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or download one.
> Doctors must complete a section and sign. Patients must also complete a section, sign and attach insurance information.
> Varies
Ship To
> Patient's home, unless otherwise noted
> This program also provides copay assistance.
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.
Procysbi capsule; delayed release
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader