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Program Details

Mylan Clozapine Patient Assistance Program

Clozapine (clozapine)
Address: 781 Chestnut Ridge Rd
Morgantown, WV 26554
Phone: 1-800-395-3376 Provider Phone:
Fax: 1-304-554-4713 Website: Mylan Clozapine Prescription Access System
Eligibility Info:
  • Patient must not have prescription coverage and is unable to pay for the medication.
  • Patient cannot exceed income limits
  • Patient must be a resident of the United States.
  • Patient, physician and pharmacy all must be registered with the Clozapine Prescription Access System.
  • Income at or below: Single 200 % FPL
      Couple 200 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: Yes
    US citizenship/residency specified: Yes
    Attachments Required: Financial
    Provide verification that alternate pharmaceutical coverage was denied.
    Physician License #
    Prescriber Signature
    Application may be
    Eligibility determination
    letter sent:
    Receives: Medication
    Shipped To: Pharmacy
    Quantity in Shipment: 90 days
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Program automatically sends refills every 90 days.
    Other Information: There are two steps and two sets of applications for this program. The first step is to register the patient with the Clozapine Prescription Access System. To register call 1-800-843-9915 or visit www.mylanclozapine.com.

    Last Updated: 06/04/2015




    Application Forms
    & Instructions

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

    DocumentForm (English)

    Document Instructions (English)


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