Letairis Co-Pay Coupon Program

Funded

About

The Letairis Co-Pay Coupon Program provides significant financial assistance for those prescribed Letairis, allowing eligible commercially insured patients to pay as little as $5 per monthly fill. With a maximum benefit of up to $20,000 per year, the program supports residents of the U.S., Puerto Rico, and U.S. Territories. Female patients must enroll in the REMS Program for treatment with Letairis, further enhancing the program's commitment to safe and accessible healthcare solutions.

Insurance requirements: Commercially insured

As low as: $5 per mo

Enrollment Forms

Enrollment Form

Benefits

•$20000 annual maximum benefit

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Must be 18 years of age or older

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: No

•Activation Required: No

Program Details

•Eligible commercially insured patients may pay as little as $5 per monthly fill

•Maximum benefit of up to $20,000 per year

•Eligible patients who are enrolled in LEAP are automatically enrolled in the Letairis CoPay Coupon Program

•All female patients MUST complete the Patient Enrollment and Consent Form to enroll in the REMS Program prior to receiving treatment with Letairis

•HCP and patient should complete the LEAP Enrollment Form and fax to 8888824035

•To complete the REMS enrollment for female patients, SIGN and FAX the REMS Patient Enrollment and Consent Form to 18667509802

•REMS enrollment form may be completed online at: http://www.ambrisentanrems.us.com/ or downloaded from: https://www.letairis.com/professional/enrollpatient

•Offer limited to one per person and is not transferable

•For additional information contact the program at 8447283479

Enrollment Forms

Enrollment Form