Zomacton Copay Assistance Program

Pharmacy Enrollment

The ZOMACTON Patient Assistance Program can be used to reduce the amount of certain uninsured or commercially insured patients’ out-of-pocket expenses, up to specified limits. This program does not constitute an insurance program.

Eligibility for the ZOMACTON Patient Assistance Program is limited to patients, or their legal guardians 18 years of age or older, who are residents of the United States and who have been prescribed Zomacton for an approved use consistent with FDA approved product labeling. Not valid for patients who are covered by any state or federally funded healthcare program, including but not limited to, Medicare (Part D or otherwise), Medicaid, Medigap, CHAMPUS, TRICARE, and any state pharmaceutical assistance program; patients who are Medicare eligible and enrolled in an employer-sponsored health plan or prescription-benefit program for retirees; or patients whose insurance plan is paying the entire cost of this prescription.

Ferring reserves the right to rescind, revoke, or amend this program at any time without notice. Program is void where prohibited by law.

Eligibility Requirements

* The patient has been prescribed Zomacton for a labeled indication.

Please select patient's label indication:

Insurance Type:

Patient Info

* Patient First Name

* Patient Date of Birth

* Patient City

* Patient State

* Patient Email

* HCP Name

* Patient Last Name

* Patient Address 1

Patient Address 2

* Patient Zip

* Best Contact Number

* Specialty

PHARMACY ATTESTATION

I verify that the patient and healthcare provider information on this enrollment form was completed by me or at my direction and I have obtained the patient's consent to enroll them in the Zomacton Patient Support Program. The information contained herein is complete and accurate to the best of my knowledge. I have received the appropriate permission and consent from the patient to comply with applicable requirements imposed under the Health Insurance Portability and Accountability Act of 1996 and applicable state laws needed to release to Ferring and its designated agents and service providers the patient-related information on this form for the purposes of verifying the patient’s insurance coverage for Product, assisting with financial assistance resources and information, such as copay support programs for which the patient may be eligible, coordinating delivery of Product, contacting the patient with education materials and training services about the patient’s prescription medication or to evaluate the effectiveness of the Program; and providing my patient with other education and support available through the Program associated with the Product.

* I have read and agree to the terms and conditions above. By clicking the Submit button, I certify that I have provided accurate and complete information.