Prialt Patient Assistance Program

Funded

About

The Prialt Patient Assistance Program offers vital support for those in need of chronic pain management by providing the drug product Prialt free of charge to eligible individuals. This program is designed for US citizens without adequate medical insurance, ensuring access to essential treatment through a simple application process. The Prialt Patient Assistance Program emphasizes ease of access and patient support, with a dedicated helpline and efficient document submission procedure.

Insurance requirements: Underinsured, Uninsured

Enrollment Forms

Enrollment Form

Program Requirements

•Valid only for residents in the US and Puerto Rico

•Enrollment Required: Yes

•Coverage Required: No

•Needs Based: Yes

•Activation Required: No

Program Details

•Patient or HCP can call the helpline to initiate the process (8556868725)

•Supporting documents (proof of residency, previous year's tax form or W2 or a notorized statement of income) must be submitted

•Eligible patients will receive Prialt free of charge, shipped to the HCP's office or infusion center

•HCP and patient must sign and complete enrollment form and fax to 18558363066

•Patients should call 18556868725 (MonFri 9:00 am to 6:00 pm ET) for further information

Enrollment Forms

Enrollment Form