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Patient Assistance Information

Trisenox Drug Replacement Program

Address: N/A
Phone : (866) 261-7730
Fax: (888) 891-4924
> The patient must have no prescription coverage for the medication and meet income guidelines that are not disclosed. The patient must also be a US citizen being treated by a US doctor. A negative decision can be appealed.
Who Can Apply
> The doctor/doctor's office should call for an application. The application will be faxed out. The completed application must be faxed back.
> The doctor must fill out a section and sign the application. The patient must fill out a section and sign the application.
> n/a
Ship To
> Doctor's office
> Once a year the application process must be repeated.
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.
Trisenox (arsenic trioxide)