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Program Details

RIGEL PHARMACEUTICALS, INC.
Rigel OneCare - Tavalisse

Tavalisse (fostamatinib disodium hexahydrate)
 
CONTACT INFO
Address:
,
Phone: 1-833-744-3562 Provider Phone:
Fax: 1-833-397-4435 Website: Program Website
ELIGIBILITY
Eligibility Info:
  • Contact program for details.
  • Program offers co-pay assistance, reimbursement support, patient support, and patient assistance programs for eligible patients.
  • Income at or below: Single 500 % FPL
      Couple 500 % FPL
    Federal Poverty Level Calculator Federal Poverty Level Calculator
    Medical expenses can be deducted from reported income: Not Published
    Social security requested on form: No
    US citizenship/residency specified: Yes
    APPLICATION
    Attachments Required: Not Published
    Physician License #
    Required:
    Both DEA and State
    NPI
    Prescriber Signature
    Allowed:
    Physician
    Application may be
    faxed:
    Yes
    Eligibility determination
    letter sent:
    Both Provider and Patient
    MEDICATION
    Receives: Varies
    Shipped To: Either Provider and Patient
    Quantity in Shipment: Not Published
    Delivery Time: Not Published
    Re-application Policy: New financial information every 12 months
    Refill Policy: Not Published
    Other Information:

    Last Updated: 02/20/2024

     

     

     


    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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