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

Sculptra Patient Access Program

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

Provided by: Valeant Pharmaceuticals, Inc.

PO Box 430
Somerville, NJ 08876

TEL: 866-310-7551

FAX: 866-364-2016
Languages Spoken:



Patient Assistance Applications

Sculptra Patient Access Program Application


Brand Name Medications Covered

  • Sculptra injection

Generic Name

  • poly-L-lactic acid injectable injection

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be citizen or legal resident


Obtaining Call
Receiving Faxed
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Patient and Doctor are notified
Decision Timeframe Within 48 hours


Amount/Supply Not specified
Sent To Doctor's office
Delivery Time Within 3 weeks of receiving application
Refill Process New application needed
Limit 3 kits within a 18 month enrollment cycle

Additional Information

Updated August 07, 2015