| |
Program Details
MERZ NORTH AMERICA
Xeomin Patient Assistance Program
Xeomin Injection
(incobotulinumtoxinA)
|
| CONTACT
INFO |
|
| Address: |
, |
| Phone: |
1-855-463-7989 |
Provider Phone: |
|
| Fax: |
1-855-825-0488 |
Website: |
Program Website |
|
| ELIGIBILITY
|
|
| Eligibility
Info: |
Patient must be uninsured or underinsured.
Patient must not be eligible for Medicare, Medicaid, or any other government program.
Must meet program income guidelines which are not disclosed.
Program offers co-payment assistance, patient support, and patient assistance programs for eligible patients |
| Income at or below: |
Not
Published |
| Medical expenses
can be deducted from reported income: |
Not
Published |
| Social security requested on form: |
Not
Published |
| US citizenship/residency specified:
|
Yes |
|
|
APPLICATION |
|
| Attachments
Required: |
Financial
|
Physician
License #
Required: |
State
NPI
|
Prescriber
Signature
Allowed: |
Physician
|
Application
may be
faxed: |
Yes |
Eligibility
determination
letter sent: |
Both Provider and Patient
|
|
| MEDICATION |
|
| Receives: |
Medication
|
| Shipped To: |
Provider
|
| Quantity in
Shipment: |
Varies |
| Delivery Time: |
Not Published
|
| Re-application
Policy: |
New application every 12 months
New financial information every 12 months
|
| Refill Policy: |
Not Published
|
| Other Information: |
|
|
|
Last Updated: 04/25/2025
|
|
Application Forms
& Instructions
The following documents
are provided in interactive PDF format, allowing you to type information
directly into the form.
 Form (English)
|
|
