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

Sebela Patient Assistance Program: Lotronex & Ridaura

This program provides brand name medications at no or low cost

Provided by: Sebela Pharmaceuticals Inc.

50 Whittemore Street
Gloucester, MA 01930

TEL: 866-562-7902


FAX: 888-246-6527 		Languages Spoken:

English

Program Website

 

Program Applications and Forms

Sebela Patient Assistance Program Application: Lotronex

Sebela Patient Assistance Program Application: Ridaura
 

Medications
  • alosetron tablet (Lotronex) Tablet
 

Eligibility Requirements   
Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case. *See Additional Information Section Below
Income At or below 300% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application
Obtaining Call or download
Receiving Faxed, emailed, mailed or downloaded
Returning Email, fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified
Decision Timeframe 5-7 business days
   

Medication
Amount/Supply Contact the program for more details.
Sent To Doctor's office or patient's home
Delivery Time Once approved; shipped next business day
Refill Process Contact program for details.
Limit None
Re-application New prescription every 3 months. New application every 6 months.
   

Additional Information
* Must not have Health insurance coverage (private or government) that pays for requested products and haven’t for at least three months.

**Medicare Part D - Copy of insurance denial letter required.

***The manufacturer supporting this program does not charge for applying to the program nor for any products applicants receive. Applicants using the services of a commercial advocacy service may have to supply additional documentation.
Updated May 22, 2023