Contact info
- Phone
- 1-833-744-3562
- Fax
- 1-833-397-4435
Eligibility
- Contact program for details.
- Program offers co-pay assistance, reimbursement support, patient support, and patient assistance programs for eligible patients.
- Income limit, single
- 500% of the federal poverty level
- Income limit, couple
- 500% 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
- Not published
- 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
- Provider or patient
- Supply per shipment
- Not published
- Time to first delivery
- Not published
- Refills
- Not published
- Staying enrolled
- New proof of income every 12 months
Medications covered
- Tavalisse (fostamatinib disodium hexahydrate)