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Program Details

GILEAD SCIENCES
Ranexa Connect Patient Assistance Program

Ranexa (ranolazine extended-release tablets)
 
CONTACT INFO
Address: PO Box 13185
La Jolla, CA 92039-3185
Phone: 1-888-726-3925 Provider Phone:
Fax: 1-888-568-9228 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be uninsured.
  • Eligible patients with government insurance, including Medicare Part D, should call program for help finding alternative financial assistance.
  • Income at or below: Not Published
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Financial
    Physician License #
    Required:
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Medication
    Shipped To: Not Published
    Quantity in Shipment: Up to 3 month supply
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    New financial information every 12 months
    Refill Policy: Patient/Provider will need to contact the program regarding refills.
    Other Information:

    Last Updated: 05/14/2015

     

     

     


    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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