|
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)
|
|
|