| Pharmaceutical Company | InterMune Pharmaceuticals |
| Program Address | 8990 Springbrook Drive, Suite 200 Minneapolis, MN 55433 |
| Toll Free Phone Number | 800-577-9112 |
| Alternate Phone Number | None |
| Fax Number | None |
| Guidelines and Notes | Patient's income must be approximately 250% of the poverty level and the patient must not be covered for medications or has capped out on their insurance coverage. |
| Initiating Enrollment | Anyone may call for the form. They will send a multiple copies to a physician or social worker |
| Health Provider's Role | The doctor completes and signs the form. Proof of diagnosis of chronic granulomatous disease is required. |
| Patient's Role | Detailed financial and insurance information is required along with proof of patient/household income. The patient must sign the form. |
| How Dispensed | Sent to a pharmacy, the patient or physician. |
| Amount Dispensed | 3 months |
| Estimated Response Time | Not specified |
| Refills | The products will be shipped every three months by calling the 800 number. A 2 week notice is appreciated. |
| Limit | Indefinite |