ADRIA LABORATORIES, INC.
Patient Assistance Program
P.O. Box 9525, McLean, VA 22102;
Adriamycin PFS, Adrucil, Folex, Idamycin, Neosar, Tarabine, and Vincasar.
supply. Physician must certify patient is unable to afford the cost of the drug, and is unable to obtain assistance
ALLERGAN PRESCRIPTION PHARMACEUTICALS
Allergan Patient Assistance Program
2525 Dupont Drive, Irvine, CA 92713;
1-800-347-4500 Ext. 4280
Betagan, Bleph-10, Epifrin, FML, HMS,
Oculinium, Pilagan, Propine, and some OTC tear products.
Course of therapy, up to a maximum of 6 months'
supply. Eligibility criteria are at the physician's discretion.
Amgen Safety Net Programs,
Medical Technology Hotlines;
EPOGEN and NEUPOGEN.
Amgen's program consists of a universal patient program and a
variable cap program for uninsured patients. Enrollment in the program is based on a patient's insurance and
F.A.I.R.(FOSCAVIR Assistance and Information on Reimbursement) Program;
Foscavir (Foscarnet Sodium)
The physician must sign and complete the application and return it within seven
days to the address indicated on the form. The qualification form must also be accompanied by a signed
PARTNERS IN HEALTH;
Persantine, Atrovent, Alupent, and Catapres
substances are not covered. Maximum of three months. Patient cannot have prescription coverage, cannot be
eligible for Medicaid/State assistance programs, and must meet annual income guidelines. Physician must initiate
Bristol-Myers Squibb Patient Assistance Program
P.O. Box 9445, McLean, VA 22102-9998;
1-800-736--0003; 703-760-0049 (FAX).
Duricef, Cefzil, BuSpar, Desyrel, Estrace, Ovcon-35, Ovcon-50,
Natalins, Natalins RX, Vagistat-1, and Mycostatin Physician's request.
(Cancer Patient Access Program)
Bristol-Myers Squibb Cancer Patient Access Program,
Lloyd Expressway, Evansville, IN 47721;
Mail Code R-22;
BICNU, CEENU, Lysodren,
Mutamycin, Mycostatin Pastilles, Paraplatin, Platinol, Platinol-AQ, VePesid, Blenoxance, Cytoxan, Lyophilized
Cytoxan, Ifex, Mesnex, and Megace Two months' supply. Internal financial screening on a case-by-case basis.
Patient Assistance Program, Burroughs-Wellcome Co.
P.O. Box 52035, Phoenix, AZ 85072-9349;
1-800-722-9294 (Program Enrollment).
Septra, Septra DS, Lanoxin, Mepron, AZT(Retrovir), Zovirax,
Zyloprim, Imuran, and WellcovorinThe products are available in a 30-day supply, with maximum of 90 days
therapy. Eligibility criteria that have to be met:
1) All applications will be reviewed within established criteria and
on a case-by-case basis.
2) Patients must be residents of the United States or territories.
3) All alternative funding
sources must be investigated.
4) All required information must be provided for consideration of eligibility.
Patients may be approved (occasionally) by exception if extreme extenuating circumstances exist.
(Patient Support Program)
Contact for the program:
Jackie LaGuardia, Senior Information Assistant,
556 Morris Ave. D2058, Summit, NJ 07901;
All the companies products
(including those distributed by Basal and Summit) are covered under the program, which include Actigall,
Anafranil, Anturane, Apresazide, Apresoline, Aredia, Brethaire, Brethine, Cataflam, Cytadren, Desferal, Esidrix,
Esimil, Estraderm, Habitrol, Ismelin, Lamprene, Lioresal, Lopressor, Lotensin, Slow-K, Tegretol, and
Transdermal-Nitro. Ritalin, a controlled substance, is not covered under this program. Up to 3 months' supply
DU PONT MERCK PHARMACEUTICAL CO.
Du Pont Pharma,
P.O. Box 80026, Wilmington, DE 19880-0026;
Drugs covered: Coumadin, Lodosyn, Sinemet, Sinemet CR, Symmetrel, Trexan, and Vaseretic. Controlled
substances are not covered, which include Percodan and Percocet. Thirty days supply. The patient must be
indigent and ineligible fora Federal or State Government pharmaceutical assistance program.
P.O. Box 2586, S. San Francisco, CA 94083-2586;
(Human Growth Hormone), Activase (TPA, Tissue Plasminogen Activator), Actimmune (Interferon Gamma-lb),
and Nutropin. Quantity provided and eligibility requirements are variable. Patients are asked to provide sufficiently
detailed information to assure the company that they are uninsured and cannot afford the required payments. (For
Activase: If an uninsured patient has gross family income of $25,000 or less, the company provides replacement
product to the hospital.)
Laura N. Wright, Supervisor
Glaxo Indigent Patient Program
P.O. Box 13438, Research
Triangle Park, NC 27709;
1-800-452-9677; 919-248-7971 (FAX)
Zantac, Ceftin, Ventolin, Beconase,
Beconase AQ, and Trandate. Maximum three months' supply. Patient must be a private outpatient whom the
physician considers medically indigent and who is not eligible for any other third-party reimbursement.
HOECHST-ROUSSEL PHARMACEUTICALS, INC.
HRPI Patient Access Program
Field Forest Development;
Products include Altrace,
ALT/S, Claforan, Diabeta, Lasix, Loprox, and Trental. Must show lack of insurance or ability to pay. The
company indicated that it provides other products to indigents upon receipt of a prescription and a physician's
letter certifying that the patient is indigent. Eligibility is on a case-by-case basis. This policy covers patients who
are ineligible for a third-party payer or Medicaid coverage. One course of therapy(usually two to three weeks).
Daria Osborne, Director
Medical Needs Program
340 Kingsland Street, Nutley, NJ 07110;
1-800-285-4489; 201-235-2765 (FAX)
They do not accept faxed applications. Valium, Librium,
Limbritol, Dalmane, Hivid, Bactrim, Bactrim DS, Klonopin, Efudex (Fluorouracil Injectable), Gantrisin, Gantanol,
Interferon 2A Recombinant, Rocephin Injectable, and Rocaltrol. Three months' supply. Eligibility limited to private
practice outpatients who are considered by the physician to be medically indigent and who are not eligible to
receive Roche drugs through any other third-party reimbursement program. The physician's signature and DEA
number are required for all applications, whether or not the request is for a controlled prescription drug. Drugs are
shipped to registered DEA addresses only.
Professional Services Immunex Corporation
Leukine 250 mcg.,
Leukine 500 mcg, Hydraea, and Rubex. Three cycles. Physician must attest that the patient requires the drug and
that all the reimbursement options for the patient have been tried.
Janssen Patient Assistance Program
1800 Robert Fulton Drive, Reston, VA 22091;
Ergamisol (levamisole HCI), Hismanal, Imodium, Nizoral, Sporanox, Duragesic, and Vermox. One or two
months' supply, varies by product. Patient must have less than $25,000 total annual household income and can
have Medicare or private insurance, but cannot have prescription coverage.
KNOLL PHARMACEUTICAL CO.
Knoll Pharmaceutical Indigent Patient Program
30 N. Jefferson Road, Whippany, NJ 07981;
Isoptin, Rythmol, and Santyl. Patients can enroll in the Heart-in-Harmony program to receive
educational information. Contact the local company sales representative, or call the patient help line. Eligible if
financially indigent and not insured.
Lederle Partners and Patient Care;
Diamox, Artane, Minocin, Leucovorin, Calcium
Loxapine, Verelan, Rheumatrex, Maxzide, and Myambutol. Physician has to make the request. Patients have to
be financially indigent, and not eligible for coverage under third-party insurance or Medicaid reimbursement.
ELI LILLY AND COMPANY
Lilly Cares, Patient Assistance Program
P.O. Box 9105, McLean, VA 22102-0105;
Ceclor, Keflex, Prozac, Dymelor, Axid and the insulin products Humulin and Iletin. The program does not cover
controlled substances, which include Darvon and Darvocet products. Quantities are dependent upon the product
and the physician's instructions. Patient's eligibility is determined on a case-by-case basis in consultation with the
prescribing physician. Patients are not required to complete enrollment forms. Physicians are asked to submit a
written request containing specific information.
MARION MERRELL DOW, INC.
Indigent Patient Program
P.O. Box 8600, Kansas City, MO 64114;
Cardizem CD, Cardizem SR, Carafate, Pavabid, Seldane, Seldane D, Nicorette, Quinamm, and Lorelco. Three
months' supply. The physician determines whether the patient is eligible for the program. Eligibility also based on
income level and lack of insurance.
Thomas Schwend, Manager
McNeil Pharmaceutical Corporation
P.O. Box 300,
Route 202 South, Raritan, NJ 08869-0602;
Pancrease, Parafon Forte DSC, Haldol, Vascor,
and Tolectin. Varies by product, patient condition. Physician determines that patient is indigent and not eligible for
health insurance. Physicians may request free medications by written or telephone request, accompanied by a
signed and dated prescription and letter stating financial status and need of patient.
MERCK & COMPANY, INC.
Patient Assistance Program,
Merck & Co., Inc.
P.O. Box 4-WP35-258, West Point, PA
215-652-5000 (collect calls accepted)
Merck products covered include Mevacor, Plendil,
Pepcid, Prilosec, Prinivil, Proscar, Timoptic, Timolol, Clinoril, Flexeril, Periactin, Noroxin, Cogentin, Indocin,
Aldomet, Dolobid, Vasoretic, and Vasotec; except injectables. Physicians only can call and request applications.
Miles Indigent Patient Program
400 Morgan Ave. West Haven, Connecticut 06516;
Cipro, Nimotop, and Tridesilon Cream. Medication quantities and duration of support is determined on a
case-by-case basis. Physician must certify that the patient is not eligible for or covered by government funded
reimbursement or insurance programs for medication. Patient's income must be below federal poverty guidelines.
ORTHO BIOTECH INC.
Ortho Biotech Financial Assistance Program
1800 Robert Fulton Drive, Reston, VA 22091-4345;
Assistance programs are for PROCRIT (Epoetin alfa) and LEUSTATIN (cladribine)Injection
1) Financial Assistance Program (FAP)1-800-447-3437 provides PROCRIT therapy free of
charge to any qualifying nondialysis patient who cannot obtain insurance coverage, is uninsured or cannot afford
the cost of their treatment.
2) Cost Sharing Program 1-800-441-1366 limits the annual cost of PROCRIT
expenditures for a patient exceeding approximately $8,500 for a calendar year, regardless of third- party
3) LEUSTATIN Financial Assistance Program 1-800-447-3437 provides LEUSTATIN therapy free
of charge to all persons who meet specific criteria and lack financial resources and third-party insurance necessary
to obtain treatment.
Thomas Schwend, Manager, Medical Information
Ortho Pharmaceutical Corporation
P.O. Box 300,
Route 202 South, Raritan, NJ 08869-0602;
Floxin, Aci-jel, Ortho Dienestrol Cream,
Monistat Vaginal Suppositories, Protostat Tablets, Sultrin Triple Sulfa Cream, Sultrin Triple Sulfa Vaginal Tablets,
Terazol3 Suppositories, Terazol 7 Cream, Spectazole Cream, Monistat-DermCream, Grifulvin Suppositories,
Meclan Cream, Persa-gel, Persa-gelW, and Erycette. Varies by product, patient condition. Physician determines
that patient is indigent and not eligible for health insurance. Physician may request free medications by written or
telephone request, accompanied by a signed and dated prescription and letter stating financial status and need of
Parke-Davis Patient Assistance Program
P.O. Box 9945, McLean, VA 22102;
products are made available which include Accupril, Cognex, Dilantin, Lopid, Neurontin, Nitrostat, Pyridium,
Procan, Sublingual and Zarontin. All applications are taken over the phone. To apply, patient or doctor calls
Parke-Davis with the following information: Doctor's full name, address, phone number; Patient's name, address,
phone number and financial status.
PFIZER, INC. PROGRAM #1
Pfizer Indigent Patient Program
P.O. Box 25457, Alexandria, VA 22314-5457;
Antivert, Marax, Diabinese, Cardura, Minizide, Navane, Sinequan, Feldene, Procardia, Procardia YL,
Vibramycin, Vistaril, Zoloft, Minipress, Minizide, and Glucotrol. Up to three months' supply at one time, as
prescribed by the physician. Any patient that a physician is treating as indigent is eligible. Patient must not be
covered by third-party insurance or Medicaid. Usually takes three to four weeks to receive medication. Refills are
available upon request by doctor.
Diflucan Patient Assistance Program
Diflucan (Fluconazole). Up to three months'
supply at one time and then can reapply. Patient must not have insurance or other third-party coverage, including
Medicaid. Patient must not be eligible for a state AIDS drug assistance program. Patient must have an income of
less than $25,000 a year without dependents; or less than $40,000 a year with dependents.
PROCTER & GAMBLE PHARMACEUTICALS, INC.
Procter & Gamble Pharmaceuticals, Inc.
17 Eaton Avenue, Norwich, NY 13815;
Asacol, Dantrium, Didronel, Macrobid, and Macrodantin. The quantity varies depending upon the situation, but at
least a one month supply can be obtained upon receipt of a physician's prescription. The company relies on the
physician's appraisal of the patient need. The company also helps the patient identify other sources of financial
help to pay for the patient's medications.
Patient Support Program
R&D Laboratories, Inc.
4094 Glencoe Avenue, Marina del Rey, CA 90292;
Every R&D Laboratories pharmaceutical nutritional supplement has a special Indigent Patient
Program sticker. Patients bring the stickers from their bottles of R&D products with them when they come to the
dialysis unit. Stickers are attached to the back of a booklet supplied by the company and the completed booklet is
returned to R&D Laboratories. For every 12 stickers we receive from a unit, R&D sends nutritional product of
facility's choice for free distribution to indigent patients.
Sandoz/NORD Drug Cost Share Program
P.O. Box 8923, New Fairfield, CT 06812;
1-800-447-6673 (for all drugs)
The National Organization for Rare Disorders (NORD)/Sandoz Drug Cost
Share Program (DCSP) is solely administered by NORD. Sandimmune, Sandostatin, Parlodel, Lescol, DynaCirc
and Eldepryl are covered under one program. Clozaril is covered under a different program, as described below.
Patient is awarded up to one year's supply of drug, which is shipped in three month supplies via the mail-order
mpharmacy utilized by the program. Clozaril-Patient is eligible to receive up to one year's supply of the drug,
dispensed only one week at a time, per dispensing requirements of package label. NORD determines eligibility by
medical and financial criteria, and applies a cost share formula. The patient/applicant must demonstrate financial
need above and beyond the availability of Federal and State funds, private insurance or family resources. NORD
also determines patient eligibility for Clozaril program.
SANOFI WINTHROP PHARMACEUTICALS
Sanofi Winthrop Pharmaceutical Needy Patient Program
Product Information Department
Avenue, New York, NY 10016;
1-800-446-6267 (Push #1 twice when automated answering
machine picks up)
Aralen, Breonesin, Bronkometer, Drisdol, Isuprel, Mytelase, NegGram, Primaquine,
Plaquenil, and Danocrine. One unit or one month's supply, as required. Subject to acceptance by the company,
patients can obtain medications by having their physician contact the company to request the product, provide a
written order for the product, and confirm the patient's need.
For Intron/Eulexin Products:
2000 Galloping Hill Road,
Building K-5-2B2, Kenilworth, NJ 07033.
For other Schering Products:
Drug Information Services
Program; 1-800-521-7157. Intron A-Initial supply is for three months; renewals available for three months at a
time. Eulexin-Initial supply is for six months; renewals available for six months at a time. Other Schering products,
which include Trinalin, Lotrimin, Lotrisone, Diprosone, Diprolene, Fulvicin, Proventil, Vancenase, Normodyne,
and Optimine, are provided for an initial three months' supply, with renewals available for up to three months at a
time. Patient eligibility is determined on a case-by-case basis, on internal criteria. The consultation includes a
review of the specific case as well as the availability of other means of health care assistance.
Patients in Need Foundation
5200 Old Orchard Road, Skokie, IL 60077;
provided include Aldactazide, Aldactone, Calan, Calan SR, Cytotec, Kerlone, Maxaquin, Norpace, and
Norpace CR. Supply is based on the physician's assessment of the needs of the patient. The program is
conducted through the physician, who determines the patient's eligibility based on medical and economic need.
Searle provides suggested guidelines to the physician for determination of patient eligibility.
SMITHKLINE BEECHAM: PROGRAM #1
SB Access to Care Program
SmithKline Beecham Pharmaceuticals
One Franklin Plaza-FP1320,
Philadelphia, PA 19101;
1-800-546-0420 (patient requests) 215-751-5722 (physician requests)
Augmentin, Relafen, Dyazide, Compazine, Bactroban, Amoxil, Ridaura, all other Smith Kline Beecham
prescription products. Individual physicians determine which patients are eligible and would benefit most from the
Access to Care Program. Physicians are required to submit forms to enroll patients in the program. Three months'
supply is available at one time. Requests must originate from the physician. Patient's prescription qualifies only if it
is not already covered under private insurance.
SMITHKLINE BEECHAM: PROGRAM #2
Eminase/Kytril/Triostat Compassionate Care Programs
SmithKline Beecham Pharmaceutical
Franklin Plaza-FP1320, Philadelphia, PA 19101;
Eminase and Triostat. Patient must
demonstrate ineligibility for other forms of medical assistance and meet the program's income requirements (single
patients with annual incomes of $18,000 or less will be eligible, and persons who are married or have at least one
dependent will be eligible if their annual incomes are $25,000 or less). For each eligible patient, hospitals should
submit a Hospital Consent Form and an Application Form with any one of the following documents: a copy of the
patient's medical record, pharmacy record, or the patient's bill.
SYNTEX LABORATORIES, INC.
Cytovene Medical Information Line; 1-800-444-4200
General telephone number to inquire about
indigent patient programs:1-800-822-8255
Cytovene (ganciclovir sodium) 500mg sterile powder. The
company's other products include Naprosyn, Anaprox, Cardene, Synalar, Synemol, Ticlid, Toradol, Lidex, and
Nasalide. Up to 25 vials of Cytovene are available. Syntex provides Cytovene free of charge when it is
prescribed for an immuno-compromised patient who has been diagnosed as having cytomegalovirus (CMV)
retinitis, if that patient lacks the means to purchase the drug, and that patient is ineligible for any form of third-party
reimbursement to pay for the drug. For information regarding other Syntex products call 1-800-822-8255.
THE UPJOHN COMPANY
Patient Assistance Program
Health Care Professionals should
contact their local Upjohn Representative. Ansaid, Motrin, Provera, E-Mycin, Halcion, Xanax, Medrol, Cleocin,
Lincocin, Loniten, Micronase, Orinase, and Tolinase. Generally, a three months' supply is provided. However, a
physician can request a supply for a longer period of time. The physician determines the patient's needs, and if
insurance or other social programs to help provide medications are available.
WYETH-AYERST LABORATORIES #1
John E. James
Wyeth-Ayerst Laboratories Indigent Patient Program
555 East Lancaster Avenue, St.
Davids, PA 19087;
Sectral, Cyclospasmol, Premarin, Isordil, Phenergan, Orudis, Wytensin,
and Cordarone. The company also makes three oral contraceptives: Triphasil, Lo/Ovral, and Nordette, which are
primarily provided by family planning clinics. In general, one to two months' supply or the closest trade package
size available is provided. For Cordarone, one month supply or up to two bottles of 60 tablets is provided. The
number of cycles of oral contraceptives given to the patient is determined by a health care provider or the family
planning clinic. The patient must be medically indigent, with no form of coverage for pharmaceutical products. The
family planning clinic determines eligibility for new and refill oral contraceptive cycles.
WYETH-AYERST LABORATORIES #2
P.O. Box 25223, Alexandria, VA 22314;
(levonorgestrel implants) five year contraceptive system. Eligibility determined on a case-by-case basis and limited
to individuals who cannot afford the product and who are ineligible for coverage under private and public sector
Yvonne A. Graham, Program Director,
Zeneca Pharmaceuticals Group
P.O. Box 15197, Wilmington,
Nolvadex, Zestoretic, Sorbitrate, Tenormin, Tenoretic, and Zestril. One to
three months' supply with application.