Transcription of Viatris Patient Assistance Program (PAP) Application
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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.
Arixtra® (fondaparinux sodium) injection, solution Cimduo® (lamivudine and tenofovir disoproxil fumarate) tablet Cortifoam® (hydrocortisone acetate 10%) rectal foam Cystagon® (Cysteamine bitartrate) capsules Denavir® (penciclovir) Cream Depen® (penicillamine tablets, USP) Titratable Tablets HC 1% 10g QTY 60mL Rectal Susp 7s QTY
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