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Viatris Patient Assistance Program (PAP) Application

Viatris and the Viatris Globe logo are trademarks of Mylan Inc., a Viatris Company. 2021 Viatris Inc. All rights reserved. Viatris Patient Assistance Program (PAP) Application | Phone: 888-417-5780 | Fax: 877-427-7290 | M-F, 8AM to 5PM EST | Please complete Application in full, sign and date, then fax to: 877-427-7290 Or email to: The PAP Application must be complete to be reviewed for Patient Program eligibility. Please ensure all areas of the form are completed in full, including all signatures. To be considered for the Viatris Patient Assistance Program , all applicants must satisfy the following requirements and eligibility criteria: o Applicants qualify for the Program financial requirements. o Applicants must be a current United States resident (includes Territories). o Applicants must be Uninsured. o The requested product must be prescribed by a licensed healthcare professional for a Food and Drug Administration (FDA) approved indication.

patient may no longer be eligible for the Program, and I agree to immediately notify a Viatris PAP representative if I become aware of changes in the patient’s financial and/or insurance status. I agree that Viatris PAP may contact me for additional …

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Viatris Patient Assistance Program (PAP) Application

www.viatris.com

Please ensure all areas of the form are completed in full, including all signatures. ... Prescriber Shipping Information (Only complete if shipping address is different than address listed above) ... the duration of the enrollment period so long as I have a legally valid prescription for my Prescribed Product. I understand that I am not ...

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