Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
 

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Egrifta Assist Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Theratechnologies, Inc.

Egrifta Patient Assistance Program
P.O. Box 390
Somerville, NJ 08876

TEL: 844-347-4382


FAX: 855-836-3069
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Egrifta Assist Patient Assistance Program Application

Egrifta Assist Statement of Medical Necessity

 

Medications

  • Egrifta injection (tesamorelin)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for the requested medication, be ineligible for federal or state programs
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Patient/Doctor's office must call or download
Receiving Downloaded from website
Returning Fax or mail
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

This program also provides co-pay and reimbursement assistance.


Updated July 14, 2017