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Patient Assistance Information

 
 
 
CORE Patient Assistance Program

PO Box 7588
Overland Park, KS 66207
Phone : 888-587-3263
Fax: 866-676-4073
Eligibility
> Patients must have no prescription coverage for the needed medication, be at or below 500% of the Federal Poverty Level, have a medically appropriate diagnosis/condition and be a citizen or legal resident.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. It can also be downloaded.
Required
> Doctors must complete a section and sign. Patients must complete a section, sign, attach a copy of proof of income, and attach front and back copy of insurance card.
Supply
> Not specified
Ship To
> Doctor's office
Note
> 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.
 
Bendeka
Granix injection
Synribo powder; subcutaneous
Treanda injection
Trisenox injection
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader