Patient Resources
Placing Patients First
Approved eligible patients may receive Gleostine at no cost, based on eligibility criteria and subject to terms and conditions*.
Healthcare provider must download the PAP enrollment form and send in as indicated on the form.
Call (877) 438-9759 for assistance.
How do I apply?
Patient Assistance Program (PAP) Terms and Conditions:
- Patient and caregiver must be a United States (U.S) citizen or resident and must physically reside in the U.S
- Patient has been prescribed Gleostine for an on-label, FDA-approved indication.
- Prescriber must complete and submit a PAP enrollment form for every patient.
- Patients whose health insurance plan or employer requires them to go through a third-party Alternative Funding Program (AFP) and apply to the PAP as a condition of, requirement for, or prerequisite to coverage of Gleostine will not be eligible for assistance from this program.
- Income criteria that demonstrate qualifying financial needs and proof of income documentation.
- Medical Expenses: Acceptable medical expenses submitted to the program should contain the amount and date of the transaction.
- Azurity reserves the right to cancel or modify the program at any time.
Questions about Patient Assistance?
For program details and eligibility, contact one of our patient advocates today!
(877) 438-9759
