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Patient Assistance Information

 
 
 
Taiho Oncology Patient Support Program

PO Box 30226
Bethesda, MD 20824
Phone : 844-824-4648
Fax: 844-287-2559
Eligibility
> Patients with insurance, including Medicare Part D, may apply. Income requirements have not been disclosed. Patients must be a US resident.
Who Can Apply
> Patients and healthcare providers can call to have an application faxed, mailed or it can be downloaded.
Required
> Doctors must complete a section of the application and sign. Patients must also complete a section, sign and attach proof of income.
Supply
> Up to 30 day supply
Ship To
> Patient's home, unless otherwise noted
Note
> * Those with Medicare Part D must reapply January 1st. All others reapply on anniversary date of when they enrolled. This program also provides reimbursement assistance.
 
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.
 
Lonsurf
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader