Program Details
DERMAVANT SCIENCES, INC.
Dermavant RxAssist Patient Assistance Program
VTAMA
(Tapinarof)
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CONTACT
INFO |
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Address: |
3780 Kilroy Airport Way Ste 250
Long Beach, CA 90806 |
Phone: |
1-833-762-8268 |
Provider Phone: |
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Fax: |
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Website: |
Program Website |
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ELIGIBILITY
|
|
Eligibility
Info: |
Uninsured Patients Only
You have existing Medicaid or Medicare coverage and can attest to financial hardship,
or VTAMA (tapinarof) cream, 1% isn't covered
Program also provides co-pay assistance.
Patient must be at least 18 years of age and a resident of the United States.
Patient must have a prescription for VTAMA (tapinarof) cream, 1%.
Visit program website to apply online. |
Income at or below: |
Single |
|
250
% FPL |
|
Couple |
|
250
% FPL |
Income at or below: |
Not
Published |
Medical expenses
can be deducted from reported income: |
Not
Published |
Social security requested on form: |
Yes |
US citizenship/residency specified:
|
Yes |
|
APPLICATION |
|
Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
MEDICATION |
|
Receives: |
Medication
|
Shipped To: |
Patient
|
Quantity in
Shipment: |
1 tube |
Delivery Time: |
0-1 week
|
Re-application
Policy: |
New application every 121 months
New financial information every 12 months
|
Refill Policy: |
Not Published
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Other Information: |
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Last Updated: 06/15/2023
www.RxAssist.org
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