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Program Details

CYSTIC FIBROSIS FOUNDATION
Patient Assistance Program

Mucomyst Solution (acetylcysteine)
 
CONTACT INFO
Address: 6931 Arlington Road
2nd Floor
Bethesda, MD 20814
Phone: 1-888-315-4154 Provider Phone:
Fax: 1-877-868-5952 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient may have insurance.
  • Patient must a diagnosis of cystic fibrosis.
  • Patient must be requesting assistance for an FDA approved medication or paired drug delivery device for the nebulized treatment of CF-related pulmonary disease, or an FDA approved medication for the treatment of pancreatic insufficiency related to CF.
  • Patient's household income must be equal to or less than 400 percent of the federal poverty level for a single CF patient household, or equal to or less than 500 percent of federal poverty level for a multiple CF patient household.
  • Income at or below: Single 400 % FPL
      Couple 400 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Other Income Requirements: For a multiple CF patient household, income must be equal to or less than 500 percent of federal poverty level.
    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
    Residency verification Copy of insurance cards, if applicable
    Physician License #
    Required:
    Not Required
    Prescriber Signature
    Allowed:
    Not Published
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Not Published
    MEDICATION
    Receives:
    Benefit Card
    Shipped To: Patient
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: New application every 12 months
    Refill Policy: Not Published
    Other Information:

    Last Updated: 10/24/2013

     

     

     


    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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