Vanflyta

Patient
Information
Eligibility
Questions
Additional
Information
Co-Pay
Card

Enter Personal Information

First Name*

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Last Name*

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Date of Birth*

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Address 1*

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Address 2

City*

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State*

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Zip Code*

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Patient
Information
Eligibility
Questions
Additional
Information
Co-Pay
Card

New Patient Eligibility

Please answer the following questions to find out if you are eligible for the VANFLYTA Co-Pay card. In order to receive benefits under the program, it is important that you provide accurate information.

*1. Are you a government beneficiary and/or participating in a federal or state-funded health care program?
This includes, but is not limited to, all Medicare (including Parts A, B, C and/or D), Medicaid, Medigap, VA, DOD and TRICARE?

Yes

Please select Yes or No.

*2. Are you currently a resident of the United States and 18 years of age or older?

Yes

Please select Yes or No.

*3. Do you have a commercial (private or nongovernmental) health plan? These include plans available through state and federal health care exchanges.

Yes

Please select Yes or No.

Enter Personal Information

New Patient Eligibility

Additional Patient Information

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