| Pharmaceutical Company | Solvay Pharmaceuticals, Inc. |
| Program Address | Solvay Patient Assistance Programc/o Express Scripts
Speciality Distribution Svc. PO Box 66550 St. Louis MO 63166-6550 |
| Toll Free Phone Number | 800-256-8918 |
| Fax Number | 800-276-9901 |
| Guidelines and Notes | Patients must be medically indigent. The company doesn't disclose income guidelines but does say that decisions are based on income and out of pocket expenses. Patient must also be a US resident and be medically indigent. If there are exacerbating circumstances that establish the patient's need, provider should attach a letter to the form. Call between 9-5 Eastern Time. |
| Initiating Enrollment | Will fax form as requested. |
| Health Provider's Role | Doctor completes, signs, ATTACHES RX and sends. |
| Patient's Role | Minimal information required, would be on-file already. Patient must provide number in household, amount of household income and out of pocket medical expenses. Patient signature not required. |
| How Dispensed | Sends medicine to doctor's o ffice within 4-6 weeks. |
| Amount Dispensed | 3 month supply (except Rowasa, 6 week supply) |
| Refills | Totally new application needed every year. |
| Limit | Indefinitely |