| Pharmaceutical Company | Xanodyne Patient Assistance Program |
| Program Address | Xanodyne Pharmacal, Inc. Patient Assistance Program 7310 Turfway Road, #490 Florence KY 41042 |
| Toll Free Phone Number | 877-926-6396 |
| Fax Number | 859-371-6391 |
| Guidelines and Notes | Application can be faxed to a provider. Be sure it is completed with all required attachments and signatures; they will not process an incomplete application. |
| Initiating Enrollment | Call for application. It is a 2 page application and they will fax it. |
| Health Provider's Role | Phyisican completes and signs form and faxes or mails in. Eligibility will be determined in 5 days. Physician must send a copy of his/her State Board Medical License with the application. |
| Patient's Role | Income and insurance information needed. Proof of pt./household income required. PATIENT must SIGN and DATE application. |
| How Dispensed | Sends medicine to doctor's office. |
| Amount Dispensed | varies by product (specified on application) |
| Refills | see below |
| Limit | Unspecified |