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This program provides brand name medications at no or low cost.
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| Pharmaceutical Company |
InterMune Pharmaceuticals |
| Program Name |
Actimmune Patient Assistance Program |
| Program Address |
PO Box 4280
Gaithersburg, MD 20885 |
| Phone Number |
800-577-9112, ext 1
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| Fax Number |
240-632-3873 |
| Medications on Program |
Actimmune Injection 100mcg/ 0.5ml (interferon gamma 1b)
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| Application Forms |
Not Applicable |
On-line Application
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No on-line application available at this time |
| Web Site |
Click to go to program's web site |
| Eligibility Guidelines and Notes |
The patient must have no prescription coverage for any medications and meet income guidelines that are not disclosed. The medication must be used for a FDA-approved diagnosis. US residency requirements are
not specified. Each applicant is handled on a case by case basis.
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| Application Process |
The health care provider, patient, social worker or patient advocate must call for a prescreening. The application is sent to the doctor's office. The completed application can be faxed or mailed back.
Both the patient and health care professional are notified of acceptance into the program. The decision is made during the phone screening, then application is sent. The medication is shipped out within 5-7 business days.
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| Application Requirements |
The doctor must fill out a section, sign the application and attach a copy of the DEA or State License number. The patient must fill out a section, sign the application and attach proof of income.
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| Program Details |
A 90-day supply is sent to the doctor's office, hospital or pharmacy. The doctor/doctor's office must contact the company to arrange refills. Once a year a new application with financial documentation is needed.
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| Last Updated |
July 30, 2010 |
