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Program Details

NOVARTIS PHARMACEUTICALS CORPORATION
Novartis Patient Assistance Foundation, Inc.

Travatan Z (travoprost solution)
 
CONTACT INFO
Address: P.O. Box 52029
Phoenix, AZ 85072-2029
Phone: 1-800-277-2254 Provider Phone:
Fax: 1-855-817-2711 Website: Novartis Patient Assistance Foundation Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must be a US resident.
  • Patient must meet program income requirements.
  • Patient must have limited or no private or public prescription coverage.
  • Income at or below: Single 600 % FPL
      Couple 600 % FPL
    Federal Poverty Level Calculator 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:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Provider
    MEDICATION
    Receives: Medication
    For some medications such as Focalin XR and Ritalin LA, a pharmacy card will be sent to the patient. The patient must take the pharmacy card and a valid prescription to their retail pharmacy to receive the product.
    Shipped To: Provider
    Note: For Clozaril, Focalin XR and Ritalin LA the patient will receive a pharmacy card.
    Quantity in Shipment: Not Published
    Delivery Time: 0-1 week
    Re-application Policy: New application every 12 months
    Refill Policy: Contact program for refills
    Other Information:
    Additional products may be available. Please contact the program for a complete product listing. www.pap.novartis.com

    Last Updated: 12/09/2020

     

     

     


    Application Forms
    & Instructions

    The following documents are provided in interactive PDF format, allowing you to type information directly into the form.


    DocumentForm (English)


    Document Form (Spanish)



     

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