Registered Users Log-in:

E-mail Address:


Forgot Password?
Patient Assistance Information

EgriftaAssist Patient Assistance Program

Egrifta Patient Assistance Program
P.O. Box 390
Somerville, NJ 08876
Phone : 844-347-4382
Fax: 855-836-3069
> Patients must have no prescription coverage for the requested medication and be ineligible for federal or state programs. Income requirements for this program have not been disclosed. Patients must have a medically necessary diagnosis/condition and be a US citizen or legal resident.
Who Can Apply
> The patient or doctor's office must call or download the application.
> Doctors must complete a section of the application, sign, and attach required documents. Patients must complete a section, sign, and attach required documents.
> Not specified
Ship To
> Not specified
> This program also provides co-pay and 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.
Egrifta injection
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
Download printable Form
(Requires Acrobat Reader