| |
Program Details
DERMAVANT SCIENCES, INC.
Dermavant RxAssist Patient Assistance Program
VTAMA
(Tapinarof)
|
| CONTACT
INFO |
|
| Address: |
3780 Kilroy Airport Way
Ste 250
Long Beach, CA 90806 |
| Phone: |
1-833-762-8268 |
Provider Phone: |
|
| Fax: |
|
Website: |
Program Website |
|
| 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 |
| Federal Poverty Level Calculator |
 |
| 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
|
| Other Information: |
|
|
|
Last Updated: 06/15/2023
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
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|
