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ViroPharma Patient Assistance Program
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PO Box 8124
Somerville, NJ 08876
Phone
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(866) 694-2547
Fax:
866-694-2549
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and have an income at or below 200% of the Federal Poverty Level. The patient must also be a US resident. The application must be filled out completely, and lab report should be attached. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. The application will be faxed out. The completed application can be faxed or mailed back. The doctor is notified of acceptance or denial. The decision is usually made within 2-3 business days. The medication is shipped within 48 hours. |
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Required
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The doctor must fill out a section and sign the application. The patient must fill out a section and sign the application. |
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Supply
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Ship To
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The medication is sent to the doctor's office. |
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Note
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A new application, new prescription and documentation of income are needed for each refill. |
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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.
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| Vancocin Capsules |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form Application Form |
(Requires Acrobat Reader) 
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