Dompé Connect to Care Patient Assistance Program

Funded

About

The Dompé Connect to Care Patient Assistance Program aims to provide financial assistance to eligible patients for the drug Oxervate. The program facilitates the enrollment process through a comprehensive support system, including the necessary coordination for the delivery and administration of Oxervate, ensuring patients receive the help they need.

Insurance requirements: Underinsured, Uninsured

Enrollment Forms

Enrollment Form

Program Requirements

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: Yes

•Activation Required: No

Program Details

•Program will determine eligibility for financial assistance

•Patient & HCP must complete and fax enrollment form for each new prescription and fax to Dompe Connect to Care at 18552631775

•Copies of front and back of all insurance cards must also be submitted if applicable

•Program can also arrange support delivery and administration of Oxervate

•For more information HCPs can call 8774224412

Enrollment Forms

Enrollment Form