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

Galderma Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Galderma Laboratories, L.P. United States

PO Box 640
Somerville, NJ 08876

TEL: 855-431-3737


ALT PHONE: 866-310-7551
FAX: 855-431-3738
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Galderma Patient Assistance Program Enrollment Application

 

Medications

  • adapalene/benzoyl peroxide gel (Epiduo Forte) Gel
  • adapalene/benzoyl peroxide gel; topical (Epiduo) Gel; Topical
 

Eligibility Requirements   

Insurance Status Must have no prescription insurance, be ineligible for any state and federal programs
Those with Part D Eligible? No
Income At or below 200% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Yes, and must be treated by US doctor
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Email, fax or mail
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 2-4 business days
   

Medication

Amount/Supply Up to 30 day supply
Sent To Doctor's office or patient's home
Delivery Time Within 5-7 business days
Refill Process Patient must contact company
Limit Up to two years
Re-application Must re-enroll at end of calendar year
   

Additional Information


Updated May 02, 2017