What does my income have to be in order to qualify for this program?
Your income will need to meet a fraction of the Federal Poverty Level guidelines.
Is US residency required to qualify?
Yes, patients must be legal US citizens and reside in one of the 50 US states, the District of Columbia, or Puerto Rico.
Am I eligible if I have Medicare coverage?
No, all government healthcare patients are excluded.
Eligibility for the ZELNORM Patient Assistance Program is subject to approval by the ZELNORM Patient Program Administrator. Submitting an application to the ZELNORM Patient Assistance Program does not guarantee program approval. The ZELNORM Patient Assistance Program can be changed, rescinded or revoked at any time without prior notice.
How do I apply?
Download and complete the application form. Call (267) 214-9644 if you need assistance.
How do I submit the application?
The completed application can be submitted by fax (908-926-2652), mail (ZELNORM Patient Assistance, 2325 Heritage Center Drive, Furlong, PA 18925), email (firstname.lastname@example.org).
How will I know if I am approved?
Patients will be notified by email provided at the time of enrollment.
How long will the approval process take?
Patients will be notified of approval/denial within one week after the application is received and determined to be complete.
Alfasigma USA, Inc. holds the highest respect for its customers and guarantees our firm commitment to your privacy. We do not sell any of the information provided by you to any other institutions.
How much medication can I receive?
Approved patients will receive a voucher good for up to six(6) monthly fills of ZELNORM.
Where will I receive my voucher?
Approved patients will receive their voucher at the address on the application.
How long will it take for me to receive my voucher?
Approved patients will receive their voucher for ZELNORM within one week after the application is received and approved.
How long will I qualify for this program if I am approved?
Once approved, patients will receive up to six months of ZELNORM and patients will need to reapply for continued support at the end of each six month period.