| |
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) 
|
| |
|
|