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Patient Assistance Information

Coverage Plus Program

PO Box 220667
Charlotte, NC 28222
Phone : (888)607-7267
Fax: (855)735-4624
> Patients must have no prescription coverage including Medicare Part D, meet income requirements that have not been disclosed and reside in the US, Puerto Rico or the USVI.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded.
> Doctors must complete a section of the application, sign and attach a prescription. Patients must also complete a section, sign and attach required documents. The application must then be faxed or mailed from the doctor's office.
> Not specified
Ship To
> Patient's home
> This program also provides copay 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.
Cuprimine Capsules
Demser Capsules (metyrosine)
Syprine capsule
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
Download printable Form
(Requires Acrobat Reader