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

CORE Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: TEVA Pharmaceuticals

PO Box 7588
Overland Park, KS 66207

TEL: 888-587-3263


FAX: 866-676-4073
Languages Spoken:

English

Program Website

 

Program Applications and Forms

CORE Enrollment Form

 

Medications

  • arsenic trioxide injection (Trisenox) Injection
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income At or below 500% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must be a US citizen or permanent resident and treated by a US licensed healthcare provider
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income, attach front and back copy of insurance card
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Not specified
Sent To Doctor's office
Delivery Time Not specified
Refill Process Automatically sent out
Limit None
Re-application New application yearly
   

Additional Information


Updated June 09, 2017