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

Arbor Patient Assistance Program for Gliadel Wafer (polifeprosan 20 with carmustine implant)

This program provides brand name medications at no or low cost

Provided by: Arbor Pharmaceuticals, LLC.

GLIADEL WAFER Patient Assistance Program
PO Box 259
Acworth, GA 30101-0259

TEL: 866-516-4950, opt. 4


FAX: 866-468-2420
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Arbor Gliadel Wafer Patient Assistance Program Application

 

Brand Name Medications Covered

 
  • Gliadel wafer: polifeprosan 20 with carmustine implant
 

Generic Name

 
  • carmustine wafer: polifeprosan 20 with carmustine implant
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income At or below 200% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be a citizen of the US and its Territories and be under the care of a US physician
   

Application

Obtaining Call or download
Receiving Downloaded from website
Returning Email, 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 2 weeks
   

Medication

Amount/Supply 1 box (includes 8 wafers)
Sent To Hospital
Delivery Time Within 2-4 business days
Refill Process Not applicable
Limit Not applicable
Re-application Not applicable
   

Additional Information


Updated November 24, 2017