Transcription of PROGRAM APPLICATION - radiuspharm.com
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PROGRAM APPLICATION - radiuspharm.com
PROGRAM APPLICATIONPATIENT ELIGIBILITY CRITERIA:Medicare BeneficiaryCommercially-Insured but Not CoveredUninsured Patient must have an FDA-approved, on-label diagnosis for TYMLOS (abaloparatide) injectionTo avoid return of an incomplete APPLICATION , complete all fields Make sure the APPLICATION is signed and dated by the prescriberDO NOT INCLUDE patient medical records with this sure the APPLICATION is signed and dated by the patientInclude all Required Documentation (see below)Fax completed APPLICATION and required documentation to 1-800-910-4610 or mail them to: Radius Assist Patient Assistance PROGRAM PO Box 5536 Louisville, KY 40255 Patient must have an Annual Household Income <300% Federal Poverty Level (FPL)* Patient must be a legal resident of the contiguous United States, Alaska, or Hawaii Patient must not be enrolled in Medicaid, Tricare, Veterans Health Administration, or Indian Health Service benefit programs Patient must not be enrolled in a Medicare or commercial prescription drug plan or Medicaid, Tricare, Veterans Health Adminis
PROGRAM APPLICATION Prescribers and Patients must review and include the required documentation, as well as complete and sign this form. Fax or mail all pages of the application as well as all required documentation to:
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