Contact info
- Phone
- 1-833-472-6369
- Fax
- 1-855-530-1382
Eligibility
- Patient must have limited or no insurance and meet program income guidelines which are not disclosed.
- Co-pay assistance is also available.
- Online Enrollment Form
- Income limit, single
- 300% of the federal poverty level
- Income limit, couple
- 300% of the federal poverty level
- Medical expenses can be deducted
- Not published
- Social Security number asked for
- No
- 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
- Medication
- 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
- Zarxio (filgrastim-sndz)