ViroPharma Patient Assistance Program
ViroPharma Incorporated Patient Assistance Program
Phone 866-694-2547
FAX COMPLETED APPLICATION TO : 866-694-2549
NOTE: NEW APPLICATION REQUIREMENTS EFFECTIVE JANUARY 2010
Download the ViroPharma Incorporated Patient Assistance Program enrollment form (PDF)
In order to expedite the processing of this application for patient eligibility, please note the following:
- The application must be filled out legibly and completely. The practitioner will be advised via faxed letter of any illegible and/or incomplete request.
- Number in household includes everyone living in the home whether related or not.
- Annual Household Income include all Wages, Social Security, Supplemental Security Income (SSI), disability, loans, unemployment, workman’s compensation benefits, pensions, alimony, child support, interest, etc. for everyone living in the home.
- Documentation/verification of income must be provided. The required document is the Federal Income Tax Return.
- A new prescription, indicating the patient’s CURRENT dose/dosage regimen, must be faxed with each request.
- A copy of recent (within past 60 days) Clostridium difficile laboratory results must be provided.
- Proof of out-of-pocket expense/cost to patient for Vancocin from patient’s pharmacy is required.
- The practitioner will be advised via faxed letter of any denied requests.
- Product will be shipped overnight to the practitioner’s office for weekday delivery only. Deliveries will be made to street addresses (No P.O. Boxes).
A maximum of 60 capsules is provided per request. An updated, original application and original prescription with current dose/dose regimen are needed every time medication is requested for an individual patient.
PROGRAM ELIGIBILITY:
- Patient must be a legal resident of the United States.
- Patient cannot currently have any government prescription coverage for Vancocin such as Medicare Part D, Medicaid, Veteran’s Administration or any state or local programs.
- Patient cannot currently have private prescription coverage for Vancocin such as an HMO or PPO plan.
- Patient’s total annual household income must be at or below 200% of the federal poverty level. (See chart below.)
| Household Size |
Max Total Annual Household Income |
Max Total Monthly Household Income |
| 1 |
$21,660 |
$1,805 |
| 2 |
$29,140 |
$2,428 |
| 3 |
$36,620 |
$3,052 |
| 4 |
$44,100 |
$3,675 |
| 5 |
$51,580 |
$4,298 |
| 6+ |
$59,060 |
$4,922 |
PLEASE NOTE: VIROPHARMA WILL MAKE EVERY EFFORT TO PROVIDE ASSISTANCE WHEN REQUESTED. HOWEVER, THIS PROGRAM IS LIMITED TO AVAILABLE RESOURCES AND MAY BE CHANGED OR DISCONTINUED AT ANY TIME.
Download the ViroPharma Incorporated Patient Assistance Program enrollment form (PDF)
To find out how to contact ViroPharma Incorporated, click here.
