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 Support Program

Provided by: Theratechnologies, Inc.

PO Box 390
Somerville, NJ 08876

TEL: 844-347-4382


FAX: 855-836-3069
Languages Spoken:

English Spanish

Program Website

 

Program Applications and Forms

Egrifta Assist Statement of Medical Necessity

Egrifta Assist Statement of Medical Necessity (Spanish)

 

Medications

  • Egrifta injection (tesamorelin)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax from Doctor's office
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 Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients.

Education and support services are available; Contact program for details.


Updated February 15, 2018