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THERAPY

Viatris Oncology
Patient Assistance Program (VOPAP)

Thank you for your interest in the Viatris Oncology Patient Assistance Program (“VOPAP”). To participate in the program, you must meet the eligibility criteria set forth below. It is important that you provide all required information and sign the application where indicated. Incomplete or incorrect applications will delay the application process, so please ensure all information is provided within 60 days. If all required information is not received within 60 days, your application cannot be approved.

Patient

  • The patient must be a resident living in the United States, and the patient must certify to this in the Patient Certification in Section 4 below.
  • The patient's gross yearly household income must fall below 500% of the current Federal Poverty Guidelines, based upon family size. Verification documents will be required.
    • Approved Verification Documents: 1040; 1040ez; W2; 4506-T; SSI Statement; Disability Statement; Statement from Physician, Nurse, or Patient Advocate; or Certified Notarized Statement from the Applicant.
  • The patient must meet one of the following:
    • The patient must not have any prescription insurance coverage, including, without limitation, coverage through Medicaid, Medicare (including Parts A&B, Medicare Advantage, or Part D), TriCare, a qualified health plan purchased on a state-based, partnership, or federally-facilitated Exchange, or any other public or private program or insurer. Verification documents will be required.
      • Approved Verification Documents: Denial Letter; Termination Statement; Statement from Physician, Nurse, or Patient Advocate; or Certified Notarized Statement from the Applicant.
    • The patient has commercial prescription drug coverage only for generic products and the patient must not have prescription insurance coverage through any state or federally funded program, including, without limitation, Medicare (including Parts A&B, Medicare Advantage, or Part D), Medicaid, or TriCare. Verification documents will be required.
      • Approved Verification Documents: Denial Letter; Termination Statement; Statement from Physician or Nurse, or Verification of Applicant’s Coverage from Insurer.
  • The patient must certify that he/she will not submit a claim for any payment for the free product or resell, trade, barter or return for credit any free product received from VOPAP.

Physician

  • The physician must complete, sign, and submit this application acknowledging that the patient has been prescribed a Viatris Oncology Product listed on page 4 of this application and is in need of assistance. (Note: Please check the appropriate box on page 4 to indicate which Viatris Oncology Product has been prescribed.)
    • Product will not be shipped to a patient’s home or to a P.O. Box.
  • The physician must certify that he/she will call the Viatris Oncology Patient Assistance Program at 800.796.9526 if the patient's prescription insurance coverage changes, if the patient’s dosage changes, or if the patient discontinues therapy.
  • The physician must certify that he/she will not submit a claim for any payment for the free product or resell, trade, barter or return for credit any free product received from VOPAP.

Completed forms and required documentation for the Viatris Oncology Patient Assistance Program should be emailed, mailed, or faxed to:

Viatris Oncology Patient Assistance Program
781 Chestnut Ridge Road
Morgantown, WV 26505
Fax: 1-877-427-7290
Email: ViatrisPAP@viatris.com

If the applicant is approved for the program, medication will be shipped to the physician’s office to be dispensed to the patient at no charge to the patient. Once the application is approved, the patient will be eligible to receive replenishment medication (as prescribed by the patient’s physician) for up to one year. A Replenishment Authorization Form will need to be filled out by the patient’s physician and returned to the Viatris Oncology Patient Assistance Program in order to receive the next replenishment. Please note that replenishment request will be considered on an as-needed basis. Please check with your healthcare professional(s) prior to placing any replenishment requests. Applicants must re-apply annually. Additional information about the Viatris Oncology Patient Assistance Program is available by calling 800.796.9526.

Viatris reserves the right to discontinue or modify this program at any time.