Contact info
- Phone
- 1-888-284-3678
- Fax
- 1-888-284-8084
Eligibility
- Patient must be uninsured or underinsured.
- Patients with Medicare Part D may be eligible, contact program for details.
- Complete Support Request Form, a PAP application will be made available after patient is prequalified,
- Co-pay assistance is also available.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- Not published
- 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
- Both DEA and state license numbers
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider and patient
Getting the medication
- Patient receives
- Varies
- Shipped to
- Patient
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- New application every 12 months
- New proof of income every 12 months
Medications covered
- Vonjo (pacritinib capsule)