| Pharmaceutical Company | Reminyl Reach Patient Assistance Program |
| Program Address | REMINYL REACH Program PO Box 222197 Charlotte NC 28222-2197 |
| Toll Free Phone Number | 866-736-4695 |
| Fax Number | 704-357-0036 |
| Guidelines and Notes | This is a separate program for this Janssen drug. |
| Initiating Enrollment | Application can be faxed or downloaded. It can be returned by mail with required documentation. |
| Health Provider's Role | Physician information is basic, original signature required. Separate prescription not needed. |
| Patient's Role | Patient required to fill in basic personal, financial and insurance information and also to attach proof of income (most recent tax return, or for patients who don't file taxes, other appropriate proof of income. Patient must sign under Applicant Declaration part of the applicati on. |
| How Dispensed | Patient, once approved, will receive a pharmacy card. |
| Amount Dispensed | 1 month supply at a time |
| Refills | After 6 months they fax a renewal form to the provider for provider and patient to complete. |
| Limit | Indefinitely |