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Patient Assistance Information
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5 Programs Sponsored By Cephalon, Inc (External Link)
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Gabitril Patient Assistance Program
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c/o InTeleCenter
PO Box 4280
Gaithersburg, MD 20885-4280
Phone
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866-209-7589
Fax:
866-209-7596
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Eligibility
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The patient must be uninsured and have an income at or below 200% of the Federal Poverty Level. The patient must also be taking the medication for an on-label diagnosis.The patient must also be a US resident. |
| Who Can Apply
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The doctor/doctor's office must call for a prescreening. |
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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. |
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Supply
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A coupon for 90-day supply |
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Ship To
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Note
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The doctor/doctor's office must call for a prescreening. |
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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.
| | Gabitril (tiagabine hydrochloride) |
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Provigil Patient Assistance Program
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C/O NORD
PO Box 1968
Danbury, CT 06813-1968
Phone
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800-675-8415
Fax:
203.798.2964
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Eligibility
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The patient must have no insurance and meet income guidelines that are not disclosed. |
| Who Can Apply
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The patient or doctor needs to call for a prescreening. |
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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. |
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Supply
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A coupon for 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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The patient or doctor needs to call for a prescreening. |
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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.
| | Provigil (modafinil) |
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Cephalon Patient Assistance Program
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Gabitril Patient Assistance Program c/o InTeleCenter
P.O. Box 4280
Gaithersburg, MD 20885-4280
Phone
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(866) 209-7589
Fax:
(866) 209-7596
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Eligibility
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Eligibiltiy is based on income, insurance coverage and diagnosis. |
| Who Can Apply
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Physician's office only |
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Required
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Proof of income is required |
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Supply
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Coupon for 90 day supply |
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Ship To
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Coupon mailed to patient's home and confirmation letter sent to physician |
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Note
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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.
| | Gabitril (tiagabine hydrochloride) |
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Fentora Reinbursement Program
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PO Box 4280
Gaithersburg, MD 20885
Phone
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877-433-6867
Fax:
866-495-0657
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Eligibility
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The patient must have no prescription coverage for any medications and meet income guidelines that are not disclosed. The patient must be a US citizen or legal resident. |
| Who Can Apply
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The patient or doctor needs to 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. |
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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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The patient or doctor needs to call for a prescreening. |
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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.
| | Fentora (fentanyl buccal) |
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Trisenox Drug Replacement Program
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Address: N/A
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Phone
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(866) 261-7730
Fax:
(888) 891-4924
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Eligibility
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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.
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| Who Can Apply
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The doctor/doctor's office should call for an application. The application will be faxed out. The completed application must be faxed back. |
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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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n/a |
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Ship To
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Doctor's office |
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Note
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Once a year the application process must be repeated. |
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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.
| | Trisenox (arsenic trioxide) |
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