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Patient Assistance Information

 
 
 
Sigma-Tau Patient Assistance Program and Reimbursement Services

200 Pinecrest
Morgantown, WV 26050
Phone : 800-490-3262
Fax: 866-694-2544
Eligibility
> Patients must have no coverage for the requested medication and be ineligible for federal or state programs. Patients must be at or below 300% of the Federal Poverty Level.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed, mailed or emailed.
Required
> Doctors must complete a section, sign, attach prescription and include their DEA and state license number. Patients must complete a section, sign, and attach a copy of proof of income.
Supply
> Up to 3 months supply
Ship To
> Doctor's office or infusion site
Note
> Insurance benefits, claims assistance and/or other reimbursement help is offered. Contact program for Spanish application.
 
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.
 
Abelcet (amphotericin B lipid complex injection)
Depocyt (cytarabine liposome)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader