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Patient Assistance Information


PO Box 220578
Charlotte, NC 28222
Phone : 855-395-3248 Ext 4
Fax: 888-335-3264
> Patients must be uninsured or underinsured. Medicare Part D recipients are not eligible. Patients must have a gross annual household income at or below $100,000 and must be a US resident.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or download one.
> Docotors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income.
> Varies
Ship To
> Doctor's office or specific site
> This program also provides copay and reimbursement 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.
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
Download printable Form
Download printable Form
(Requires Acrobat Reader