Program Details
HORIZON PHARMA USA, INC.
Horizon By Your Side - Procysbi
Procysbi
(cysteamine bitartrate delayed-release capsule)
|
| CONTACT
INFO |
|
| Address: |
Horizon Patient Services 1 Horizon Way
Deerfield, IL 60015 |
| Phone: |
1-855-888-4004 |
Provider Phone: |
|
| Fax: |
1-877-773-9411 |
Website: |
Program Website |
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| ELIGIBILITY
|
|
| Eligibility
Info: |
Eligibility determined on case-by-case basis.
Program offers co-pay assistance, reimbursement support, and patient assistance programs for eligible patients.
Patients with Medicare Part D may be eligible, contact program for details.
Income eligibility based on FPL.
|
| |
Couple |
|
% FPL |
| 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: |
Insurance information
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes
|
Eligibility
determination
letter sent: |
Not Published
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Varies
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
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Last Updated: 04/04/2024
www.RxAssist.org
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