| |
Program Details
ACROTECH BIOPHARMA
STAR Specialty Therapy Access Resources
Beleodaq Powder
(belinostat)
|
| CONTACT
INFO |
|
| Address: |
PO Box 220551
Charlotte, NC 28222-0551 |
| Phone: |
1-888-537-8277 |
Provider Phone: |
|
| Fax: |
1-866-930-1562 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Contact program for details.
Co-pay assistance, reimbursement support, patient support, and patient assistance programs are available for eligible patients. |
| 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:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Insurance information, if applicable
|
Physician
License #
Required: |
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Not Published
|
|
| MEDICATION |
|
| Receives: |
Not Published
|
| Shipped To: |
Not Published
|
| Quantity in
Shipment: |
Not Published
|
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
Not Published |
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 03/05/2024
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
|
|
