Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Updated October 01, 2014

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


ALT PHONE:
FAX: 866-364-2016
Languages Spoken:

English

 

Patient Assistance Applications

Sculptra Patient Access Program Application

 

Brand Name Medications

 
  • Sculptra Injectable dosage varies (poly-L-lactic acid injectable)

Generic Medications

 
  • poly-L-lactic acid injectable Injectable dosage varies
 

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
   

Application

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
   

Medication

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
Re-application
   

Additional Information