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Program Details

GILEAD SCIENCES
LEAP Patient Support Program

Letairis Tablets (ambrisentan)
 
CONTACT INFO
Address:
,
Phone: 1-866-664-5327 Provider Phone:
Fax: Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient must meet program guidelines which are not disclosed.
  • Eligibility for Medicare Part D patients is determined on a case-by-case basis.
  • Co-pay assistance is also available.
  • 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: None
    Physician License #
    Required:
    Not Published
    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: Not Published
    Delivery Time: Not Published
    Re-application Policy: Reapplication is determined on a case-by-case basis
    Refill Policy: Patient must contact pharmacy
    Other Information:

    Last Updated: 02/02/2024

     

     

     


    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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