Contact info
- Phone
- 1-844-817-6468
- Fax
- 1-844-269-3038
- Mailing address
- PO Box 4280Gaithersburg, MD 20885-4280
Eligibility
- Patient is uninsured or the prescribed medication is not covered.
- Patients with Medicare Part D are not eligible.
- Co-Pay Assistance Program also available. Call program for details.
- Income limit, single
- Not published
- Income limit, couple
- Not published
- 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
- Prescription
- Prescriber license number
- NPI number
- State license number
- Who can sign
- Physician
- Application can be faxed
- Yes
- Decision letter sent to
- Provider
Getting the medication
- Patient receives
- Medication
- Shipped to
- Patient
- Supply per shipment
- 30-day supply
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- Not published
Medications covered
- Alunbrig (brigatinib)
- Fruzaqla (fruquintinib)
- Iclusig (ponatinib)
- Ninlaro (ixazomib)