Lonsurf Prescription Assistance Programs

Lonsurf: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Lonsurf. Review the information to see if you qualify. The applications are available in Adobe PDF format and should be mailed directly to the provider of the patient assistance program.

If you have any questions, please call the telephone number for the program (not PharmacyChecker.com) or go to the program website.

Looking for a different medication?

Patient Access Network Foundation (PAN)

(Program 1 of 2 — Scroll down to see them all )

Provided by: Patient Access Network Foundation
None
TEL: 866-316-7263
FAX: 866-316-7261
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Lonsurf (trifluridine and tipiracil)
Eligibility Requirements
  • Insurance Status *See Additional Information section below
  • Those with Part D Elibible? Determined case by case
  • Income Between 400-500% of FPL
  • Diagnosis/Medical Criteria FDA Approved Diagnosis - See Program Website for Details
  • U.S. Residency Required? Must reside and receive treatment in US
Application
  • Obtaining Call or complete online
  • Receiving Complete online or by phone
  • Returning Complete online or by phone
  • Doctor's Action Will be discussed with patient and Doctor after request is received
  • Applicant's Action Call for information or inform doctor that he/she is in need
  • Decision Communicated Patient and Doctor notified in writing
  • Decision Timeframe Within 48 hours
Medication
  • Amount/Supply Not applicable
  • Sent To Patient sent card to be used at pharmacy
  • Delivery Time Once approved; shipped same day
  • Refill Proces Patient presents voucher/card to pharmacy for each refill
  • Limit None
  • Re-application New application every 12 months
Additional Information
*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance. Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly. Note: All new enrollment is now done electronically or over the phone. Contact program for details.
Updated August 6, 2019

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

Back to top

Taiho Oncology Patient Support Program

(Program 2 of 2 — Scroll down to see them all )

Provided by: Taiho Oncology, Inc.
PO Box 30226 Bethesda, MD 20824
TEL: 844-824-4648
FAX: 844-287-2559
Languages Spoken:
English, Spanish, Others By Translation Service
Program Website
Medications
  • Lonsurf (trifluridine and tipiracil)
Eligibility Requirements
  • Insurance Status May have insurance
  • Those with Part D Elibible? Yes
  • Income Not disclosed
  • Diagnosis/Medical Criteria Not required
  • U.S. Residency Required? Must be a US resident and treated by a US licensed healthcare provider
Application
  • Obtaining Call or download
  • Receiving Faxed, mailed or downloaded from website
  • Returning The completed application can be faxed or mailed back.
  • Doctor's Action Complete section and sign
  • Applicant's Action Complete section, sign, attach a copy of proof of income
  • Decision Communicated Patient and Doctor are notified
  • Decision Timeframe Within 24-48 hours
Medication
  • Amount/Supply Up to 30 day supply
  • Sent To Patient's home, unless otherwise noted
  • Delivery Time Shipped overnight
  • Refill Proces Company contacts patient to arrange
  • Limit None
  • Re-application *See Additional Information section below
Additional Information
* Those with Medicare Part D must reapply January 1st. All others reapply on anniversary date of when they enrolled. This program also provides reimbursement assistance.
Updated July 30, 2019

If you, your patient or loved one does not qualify for this program or other prescription savings programs, then please search for prices here.

Back to top