Contact info
- Phone
- 1-833-876-4361
- Fax
- 1-833-664-7216
Eligibility
- Eligibility determined on case-by-case basis.
- Program offers co-pay assistance, reimbursement support, and patient assistance programs for eligible patients.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- Yes
- US citizenship or residency required
- Yes
Not sure where your income falls? See this year's federal poverty guidelines (opens in a new tab).
Application process
- Documents to attach
- Not published
- Prescriber license number
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Not published
Getting the medication
- Patient receives
- Medication
- Shipped to
- Provider
- Supply per shipment
- 1 dose
- Time to first delivery
- Not published
- Refills
- Physician's office must contact program
- Staying enrolled
- Not published
Medications covered
- Jelmyto (mitomycin)