| Pharmaceutical Company | Three (3) M Pharmaceuticals |
| Program Address | 3M Pharmaceuticals Patient Assistance Program 3M Center Bldg. 275-6W-13 St. Paul, MN 55144 |
| Toll Free Phone Number | 800-328-0255 |
| Fax Number | 651-733-6068 |
| Guidelines and Notes | Patient must have no prescription coverage for ANY medications, be ineligible for any state or federal assistance, and not be able to buy the medication. Physician should only refer patient's whose income, in their judgement, is so low that purchasing the medication is causing unreasonable hardship. Patient's income should be below 200% of the federal poverty level. |
| Initiating Enrollment | Physician's office or social worker must call for authorization form with: prescriber's name, phone, degree, address, patient's name and medication /strength needed. The authorization form is patient specific and can't be copied. |
| Health Provider's Role | Authorization form is patient-specific and is sent to physician for signature and DEA or State License number. |
| Patient's Role | Patient provides income, household, insurance, medical and prescription expense information. PATIENT SIGNATURE REQUIRED. |
| How Dispensed | Sends medicine to physician or to a specified pharmacist at a hospital or health care entity. |
| Amount Dispensed | Varies according to product -- Aldara: 1 box of 12 packets; Maxair Autohaler: 3 inhalers MetroGel: one 70 gm tube; Minitran: 120 patches (4 mos. supply); all tablets: 300 tablets |
| Refills | Not specified |
| Limit | Indefinitely |