•Eligible underinsured patients may be able to receive medication at no cost for up to one year
•Program provides medication cost assistance only; does not cover the costs to receive treatment
•Patients with Medicare Part D may be asked to submit a report from their pharmacy or an EOB statement from their insurance that shows their outofpocket costs for the current year
•HCP should fax the completed enrollment form and supporting documents to: 8662790669
•For assistance or additional information, call 8337420791, Monday through Friday, 8:00 am to 8:00 pm ET