| |
SHARE Patient Assistance Program
|
,
Phone
:
(888)457-4273
Fax:
(877)742-1002
|
|
Eligibility
|
| > |
SHARE Patient Assistance Program is a program that provides brand name medications at no or low cost. Patients with insurance, including Medicare Part D are eligible for this program. Income requirements are based on the federal poverty level. Patients must have an FDA-approved diagnosis and must reside in the US. |
| Who Can Apply
|
| > |
Doctors must fax a referral for this program. |
|
Required
|
| > |
Doctors must fax a referral for this program and provided patient with prescription. Program will contact patient for information. A new application is needed yearly. |
|
Supply
|
| > |
Up to 30 day supply. Pharmacy will contact patient for refill. |
|
Ship To
|
| > |
Patients home |
|
Note
|
| > |
Insurance benefits, claims assistance and/or other reimbursement help is offered. |
| |
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.
|
| Sabril oral solution |
| Sabril tablet |
| |
| |
|
|
| |
Xenazine Information Center
|
PO Box 8725
Gaithersburg, MD 20898
Phone
:
888-882-6013
Fax:
866-341-5601
|
|
Eligibility
|
| > |
Xenazine Information Center is a program that provides brand name medications at no or low cost. Insurance requirements are determined on a case by case basis. Income requirements for this program are not disclosed. Diagnosis and residency requirements have not been specified. |
| Who Can Apply
|
| > |
Patients and doctors can call or download the application. |
|
Required
|
| > |
Doctors and patients must complete and sign the application and fax it back. |
|
Supply
|
| > |
Varies |
|
Ship To
|
| > |
Patient's home, doctor's office, hospital or pharmacy. |
|
Note
|
| > |
Depending on insurance coverage, REACH (Resources, Education and Access for patients with Chorea associated with Huntington's disease) offers a variety of services: Information Center, Starter Rx prescription supply, Copay/Co-Insurance Assistance and Patient 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.
|
| Xenazine tablet |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|
| |
ONFI Patient Assistance Program
|
,
Phone
:
855-345-6634
Fax:
855-547-8278
|
|
Eligibility
|
| > |
ONFI Patient Assistance Program eligibility is determined on a case by case basis. Income requirements have not been disclosed for this program. Medication must be medically necessary as determined by a doctor. US residency requirements have not been specified. |
| Who Can Apply
|
| > |
Doctors |
|
Required
|
| > |
Doctors must send a referral form to the program to begin the application process. The form can be faxed, mailed or downloaded. Doctors must complete and sign and fax or mail from their office. |
|
Supply
|
| > |
Not specified |
|
Ship To
|
| > |
Not specified |
|
Note
|
| > |
Resources for HEALTHCARE PROFESSIONAL ONLY.
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.
|
| Onfi tablet |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
|
|
| |
Northera Support Center
|
,
Phone
:
844-601-0101
Fax:
844-601-0102
|
|
Eligibility
|
| > |
Northera Support Center provides medication at low or no cost and is intended for patients that do not have prescription coverage for the needed medication. Medicare Part D patients are not eligible. Income requirements for this program have not been disclosed. Patients must have an FDA-approved diagnosis and must be a US resident. |
| Who Can Apply
|
| > |
Doctor or doctor's office must call. |
|
Required
|
| > |
Patients must inform the doctor that they are in need. The doctor or doctor's office must call and download form from the link below. Doctor's must complete and sign the application and fax back with any necessary documents. Re-applications are determined on a case by case basis. |
|
Supply
|
| > |
As prescribed by the doctor. The company will contact the patient to arrange refills. |
|
Ship To
|
| > |
Patient's home |
|
Note
|
| > |
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.
|
| Northera capsule |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
|
|