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Program Details

TAKEDA ONCOLOGY
Takeda Oncology Here2Assist

Fruzaqla (fruquintinib)
 
CONTACT INFO
Address: PO Box 4280
Gaithersburg, MD 20885-4280
Phone: 1-844-817-6468 Provider Phone:
Fax: 1-844-269-3038 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Patient is uninsured or the prescribed medication is not covered.
  • Patients with Medicare Part D are not eligible.
  • Co-Pay Assistance Program also available. Call program for details.
  • 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: Financial
    Prescription
    Physician License #
    Required:
    State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Provider
    MEDICATION
    Receives: Medication
    Shipped To: Patient
    Quantity in Shipment: 30 days
    Delivery Time: Not Published
    Re-application Policy: Not Published
    Refill Policy: Not Published
    Other Information:

    Last Updated: 02/26/2024

     

     

     


    Application Forms
    & Instructions

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


    Document Here2Assist Enrollment Form


    Document Patient Assistance Application


    Document Spanish Patient Assistance Application



     

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