Program Details
MELINTA THERAPEUTICS, INC.
ORBACTIV Support Program
Orbactiv
(oritavancin)
|
| CONTACT
INFO |
|
| Address: |
290 W. Mt. Pleasant Ave Building 2, 4th Fl., Suite 4210
Livingston, NJ 070309 |
| Phone: |
1-844-672-2284 |
Provider Phone: |
|
| Fax: |
1-855-886-2482 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be uninsured.
Patient must meet household income requirements
Co-pay assistance is also available. |
| |
Couple |
|
% 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:
|
Not
Published |
|
|
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: |
Not Published
|
| Shipped To: |
Varies
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 04/26/2024
www.RxAssist.org
|