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Carnitor Drug Assistance Program
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Carnitor Drug Assistance Program
C/O NORD
Danbury, CT 06813-1968
Phone
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855-653-3220
Fax:
203-349-3279
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Eligibility
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The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must be diagnosed with Carnitene Definciency, be a US resident and have a prescription from a US doctor. |
| Who Can Apply
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The doctor, patient, social worker or patient advocate must call for a prescreening. |
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Required
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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Up to a 90-day supply |
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Ship To
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Patient's home |
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Note
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Assistance may be give from 25-100% for up to 1 year. Negative decision may be appealed. |
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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.
| | Carnitor (levocarnitine) | | Carnitor Injection | | Carnitor Oral Solution | | Carnitor Sugar Free Oral Solution |
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Matulane Patient Assistance Program
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Matulane Patient Assistance Program
C/O NORD
Danbury, CT 06813-1968
Phone
:
855-653-3220
Fax:
203-349-3282
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Eligibility
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The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. Patient must also have a diagnosis of Stage III or IV Hodgkin's Disease or have another lymphoma where a physician feels a response is possible.The patient must also be a US resident. |
| Who Can Apply
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Anyone with the patient's and the doctor's information can call. |
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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, sign the application and attach proof of income and any insurance information. |
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Supply
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30 day supply |
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Ship To
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Either Doctor's office or Patient's home |
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Note
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The patient is given 25%-100% assistance for up to one year. Negative decision may be appealed. |
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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.
| | Matulane (procarbazine HCL) |
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Sigma-Tau Patient Assistance Program and Reimbursement Services
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200 Pinecrest
Morgantown, WV 26050
Phone
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800-490-3262
Fax:
866-694-2544
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Eligibility
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Patients must have no coverage for the requested medication and be ineligible for federal or state programs. Patients must be at or below 300% of the Federal Poverty Level. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed, mailed or emailed. |
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Required
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Doctors must complete a section, sign, attach prescription and include their DEA and state license number. Patients must complete a section, sign, and attach a copy of proof of income. |
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Supply
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Up to 3 months supply |
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Ship To
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Doctor's office or infusion site |
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Note
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Insurance benefits, claims assistance and/or other reimbursement help is offered.
Contact program for Spanish application. |
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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.
| | Abelcet (amphotericin B lipid complex injection) | | Depocyt (cytarabine liposome) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form | (Requires Acrobat Reader) 
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VSL#3 DS Medical Food Patient Assistance Program
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,
Phone
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877-279-2459
Fax:
203-349-8172
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Eligibility
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Patients must be uninsured, have Ulcerative Colitis or Pouchitis and be a US resident. There are no income limits for this program. |
| Who Can Apply
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Patients must call to have an application sent to them. |
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Required
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Doctors and patients must both complete a section and sign. |
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Supply
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Varies |
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Ship To
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Patient's home |
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Note
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The program covers VSL#3 DS packets, not capsules. |
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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.
| | VSL 3 DS concentrated probiotic |
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