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Patient Assistance Information

 
 
 
Solstice Co-Pay Assistance Program

4700 Millenia Blvd., Suite 310
Orlando, FL 32839
Phone : 888-461-2255 Ext 3
Fax: 888-343-3275
Eligibility
> Patients must not have public insurance but may have private insurance. Patients must be at or below 350% of the Federal Poverty Level and have Cervical Dystonia. Massachusetts residents are not eligible.
Who Can Apply
> Doctor of hospital must call to have an application faxed or mailed.
Required
> Doctor starts the process by submitting an insurance verification request online or via fax. Patients must complete a section of the application, sign, attach proof of income and attach any insurance information.
Supply
> Not applicable
Ship To
> Not applicable
Note
>
 
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.
 
Myobloc (botulinum toxin type B)
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader