Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated October 09, 2014
 

Daraprim

Amedra Cares Patient Assistance Program

This program provides brand name medications at no or low cost.

Provided by: Amedra Pharmaceuticals

PO Box 66553
St. Louis, MO 63166-6533

TEL: 877-908-8583


ALT PHONE:
FAX: 877-908-9987
Languages Spoken:

English

 

Patient Assistance Applications

Amedra Cares Patient Assistance Program Application

 

Medications

  • Daraprim Tablet 25mg (pyrimethamine)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? No
Income At or below 200% of FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be a US resident
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section, sign, attach original prescription
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Not specified
Decision Timeframe Within 4-5 business days
   

Medication

Amount/Supply Up to 90 day supply
Sent To Patient's home, unless otherwise noted
Delivery Time Shipped overnight
Refill Process No Refills. New Prescription must be submitted for each fill
Limit Up to one year
Re-application New application, new documentation yearly
   

Additional Information

Each prescription must be an original, or faxed from the physician's office with a cover sheet or an acceptable fax header.