Promise of Support Program

Information last checked December 16, 2024

Contact info

To enroll patient, provider must first enroll in REMS and complete a prescription form for the patient. Program will then determine patient's coverage.
Providers should fax the REMS form to: 1-866-205-3072
Prescription form should be faxed to: 1-877-788-4948 or fax to 1-877-827-0395 during weekends and after business hours.
Program offers patient assistance for the uninsured as well as Bridge programs and co-pay assistance for the underinsured.
To be eligible for PAP, patient must be uninsured or functionally uninsured and meet program income guidelines. Patient must be treated by a licensed US healthcare provider and have a valid prescription for the medication. Must be for an FDA-approved indication.
Patients with Medicare, Medicaid and other federal or state programs may be ineligible for certain aspects of the program.

Information last checked December 16, 2024

To enroll patient, provider must first enroll in REMS and complete a prescription form for the patient. Program will then determine patient's coverage.
Providers should fax the REMS form to: 1-866-205-3072
Prescription form should be faxed to: 1-877-788-4948 or fax to 1-877-827-0395 during weekends and after business hours.
Program offers patient assistance for the uninsured as well as Bridge programs and co-pay assistance for the underinsured.
To be eligible for PAP, patient must be uninsured or functionally uninsured and meet program income guidelines. Patient must be treated by a licensed US healthcare provider and have a valid prescription for the medication. Must be for an FDA-approved indication.
Patients with Medicare, Medicaid and other federal or state programs may be ineligible for certain aspects of the program.