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Program Details

TEVA PHARMACEUTICALS
Copaxone Patient Assistance Program

Copaxone (glatiramer acetate)
 
CONTACT INFO
Address: Shared Solutions
PO Box 7588
Overland Park, KS 66207-0588
Phone: 1-800-887-8100 Provider Phone:
Fax: Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Each case is reviewed idividually, but is based program details which are not disclosed.
  • Patient must be uninsured or underinsured.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Not Published
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Not Published
    Physician License #
    Required:
    Not Published
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    No
    Eligibility determination
    letter sent:
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: Up to 30 or 90 day supply
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: Patient to contact program regarding refills.
    Other Information:

    Last Updated: 02/27/2014

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.



     

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