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VeltassaKonnect
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PO Box 43848
Louisville, KY 40253
Phone
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844-870-7597
Fax:
888-623-7092
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Eligibility
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Patients must be uninsured or underinsured. Medicare Part D recipients are not eligible for this program. Income requirements and diagnosis criteria for this program have not been disclosed. Patients must reside in the US, DC, Puerto Rico or the US Virgin Islands. |
| Who Can Apply
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Patients or healthcare providers can download an application. |
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Required
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Doctors must complete a section, sign, and attach required documents. Patients must complete a section, sign, and attach required documents. |
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Supply
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Varies |
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Ship To
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Patient's home |
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Note
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*The patient receives a free 10-day supply of VELTASSA directly—even before coverage is determined. If the benefit verification process takes longer than expected, a second 10-day supply of VELTASSA will be shipped to your patient at no cost. |
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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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| Veltassa |
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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 |
(Requires Acrobat Reader) 
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