Contact info
- Phone
- 1-833-533-5299
- Fax
- 1-855-593-3955
Eligibility
- Patient must have no prescription coverage for needed medication.
- Patients with Medicare Part D are not eligible.
- Program offers co-pay assistance, and patient assistance programs for eligible patients.
- Income limit, single
- 400% of the federal poverty level
- Income limit, couple
- 400% of the federal poverty level
- 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
- Proof of income
- Prescriber license number
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Patient
Getting the medication
- Patient receives
- Medication
- Shipped to
- Not published
- Supply per shipment
- Up to 1-month supply
- Time to first delivery
- 0–2 weeks
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Rylaze (asparaginase erwinia chrysanthemi recombinant-rywn injection)