ViroPharma Patient Assistance Program

ViroPharma Patient Assistance Program
P.O. Box 8124
Somerville, NJ 08876
Phone 866-694-2547
Fax: 866-694-2549

In order to expedite the processing of this application for patient eligibility, please note the following:

• The form must be filled out legibly and completely.
• Number in household includes everyone living in the home.
• Household income includes Social Security, Supplemental Security Income (SSI), disability, unemployment, workman's compensation benefits, pension, alimony, loans, child support, interest, etc.
• The patient's prescription must be faxed with each request.
• Documentation of income (e.g., most recent tax return, W2, pay stub) must be provided for all repeat applicants.
• Fax the application to 866-694-2549 (include federal tax return/income verification if repeat applicant)
• All incomplete applications will be returned to the practitioner for completion.
• Both the patient and practitioner will be advised in writing of any denied requests.
• Product will be shipped overnight to the practitioner's office. Deliveries will be made to street addresses only (No P.O. Boxes).

An updated, original application is needed every time medication is requested for an individual patient.

Program Eligibility:

• Patient must be a legal resident of the United States.
• Patient cannot have or qualify for any government prescription coverage such as Medicare, Medicaid, Veteran's Administration or any state or local programs.
• Patient cannot have or qualify for any private prescription coverage such as an HMO or PPO plan.
• Patient's total annual household income must be at or below 200% of the federal poverty level.

 

Download the ViroPharma Patient Assistance Program enrollment form (29k pdf)

Please note: ViroPharma will make every effort to provide assistance when needed. This program is limited to available resources and may be changed or discontinued at any time.

To find out how to contact ViroPharma Incorporated, click here