Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
 
 
MS One to One Patient Assistance Program

One to One Support Services
PO Box 220790
Charlotte, NC 28222
Phone : (855)676-6326
Fax: (855)557-2478
Eligibility
> Must be uninsured or rendered uninsured. Medicare PartD patients not eligible. Income must be at or below 500% of FPL. Must be US citizen or legal entrant.
Who Can Apply
> Call for application to be faxed or download from website. Application must be faxed back to company from Doctor's office.
Required
> Medically appropriate condition/diagnosis required. Doctor must complete section and sign. Patient must complete section, sign application and consent. Patient will be notified of decision.
Supply
> Amount/supply not specified. Refills are automatically sent out. Refill limit of 1 year. Company contacts patient about reapplying.
Ship To
> Ship to Patient's home.
Note
> Patient must have a US prescriber.
 
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.
 
Aubagio tablet
Lemtrada
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form MS One to One Patient Assistance Program
(Requires Acrobat Reader