Ravicti Patient Assistance Programs

Ravicti: Apply for prescription assistance below

If you are eligible, the programs below can help you afford Ravicti. 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?

HealthWell Foundation Copay Program

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

Provided by: HealthWell Foundation
PO Box 220410 Chantilly, VA 20153-0410
TEL: 800-675-8416
FAX: 800-282-7692
Languages Spoken:
English, Others By Translation Service
Program Website
Medications
  • Ravicti (glycerol phenylbutyrate)
Eligibility Requirements
  • Insurance Status May have insurance
  • Those with Part D Elibible? Yes
  • Income Varies
  • Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
  • U.S. Residency Required? The patient must also be residing in the US.
Application
  • Obtaining Call or complete online
  • Receiving Sent out or may be completed online
  • Returning The completed application must be 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 notified in writing
  • Decision Timeframe 3-5 business days
Medication
  • Amount/Supply Not applicable
  • Sent To Varies
  • Delivery Time Not specified
  • Refill Proces Good for one year
  • Limit Not specified
  • Re-application New application every 12 months
Additional Information
This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease. Call for most recent medications as the list is subject to change.
Updated November 1, 2018

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Horizon Cares

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

Provided by: Horizon Pharma USA, Inc.
None
TEL: 866-479-6742
Languages Spoken:
English
Program Website
Program Applications and Forms
Medications
  • Ravicti (glycerol phenylbutyrate)
Eligibility Requirements
  • Insurance Status Determined case by case
  • Those with Part D Elibible? Not specified
  • Income Determined case by case
  • Diagnosis/Medical Criteria FDA-approved diagnosis
  • U.S. Residency Required? Must be a US resident
Application
  • Obtaining Call or download from Programs website
  • Receiving Faxed or downloaded from website
  • Returning Varies
  • Doctor's Action Varies
  • Applicant's Action Inform Doctor that he/she is in need
  • Decision Communicated Not specified
  • Decision Timeframe Not specified
Medication
  • Amount/Supply Varies
  • Sent To Not specified
  • Delivery Time Not specified
  • Refill Proces Not specified
  • Limit Not specified
  • Re-application Not specified
Additional Information
Co-payment assistance, reimbursement support, and patient assistance programs are available for eligible patients. Contact program for details.
Updated October 16, 2018

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