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.
300/300mg T 30s QTY 10% 15g QTY 50mg C 500s QTY 150mg C 500s QTY 1% 5gm QTY 250mg T 100s QTY 250mg C 100s QTY 137/50mcg Nasal Spray 23g QTY 0.06% Gel 35g Dual Pack QTY Dipentum® (olsalazine sodium) capsule Dymista® azelastine hydrochloride & fluticasone propionate) nasal spray Elestrin® (estradiol gel) 0.06% Arixtra® (fondaparinux …
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