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Patient Assistance Information

Daraprim Direct Program

Phone : 844-267-3323
Fax: 877-241-1365
> Insurance status will be considered on a case by case basis. Patients must meet income requirements that have not been disclosed and have a medically appropriate condition/diagnosis.
Who Can Apply
> Doctors can call for an application or download one.
> Patients must inform the doctor that they are in need. Doctors must complete a section of the application, sign and attach required documents.
> Not specified
Ship To
> Not specified
> Resources for HEALTHCARE PROFESSIONALS ONLY. This program provides delivery, reimbursement and support services.
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.
Daraprim Tablets
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader