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.
Erygel® (erythromycin) Topical Gel USP, 2% Evoclin® (clindamycin phosphate) Foam, 1% Felbatol® (felbamate) Gastrocrom® (cromolyn sodium, USP) oral concentrate 100mg 5mL Oral Concentrate 96s 0.12% 100gm QTY 0.12% 50gm QTY 200 IU/mL 2mL MDV 1pk QTY 250mcg Suppository 6s QTY 500mcg Suppository 6s QTY 1000mcg Suppository 6s QTY 0.05% 50gm …
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