Placing Patients First
Approved eligible patients may receive Gleostine at no cost, based on eligibility criteria and subject to terms and conditions*.
Healthcare provider must download the PAP enrollment form and send in as indicated on the form.
Call (877) 438-9759 for assistance.
How Do I Apply?
*Patient Assistance Program (PAP) Terms and Conditions:
- Patient and caregiver must be a United States (U.S) citizen or resident and must physically reside in the U.S
- Patient has been prescribed Gleostine for an on-label, FDA-approved indication.
- Prescriber must complete and submit a PAP enrollment form for every patient.
- Patients whose health insurance plan or employer requires them to go through a third-party Alternative Funding Program (AFP) and apply to the PAP as a condition of, requirement for, or prerequisite to coverage of Gleostine will not be eligible for assistance from this program.
- Income criteria that demonstrate qualifying financial needs and proof of income documentation.
- Medical Expenses: Acceptable medical expenses submitted to the program should contain the amount and date of the transaction.
- Azurity reserves the right to cancel or modify the program at any time.
