Strativa Patient Assistance Program
Qpharma
The Strativa PAP provides medication to patients who cannot otherwise afford their medication. Patients must be US residents and qualify for the program based on annual household income and lack of prescription coverage.
Contact Information
Strativa Patient Assistance Program
PO Box 1475
Morristown, NJ 07962
1-(800) 589-0841 (phone)
1-(973) 644-3308 (fax)
Strativa Patient Assistance Program
PO Box 1475
Morristown, NJ 07962
1-(800) 589-0841 (phone)
1-(973) 644-3308 (fax)
Physician requests should be directed to:
1-(800) 589-0841 (phone)
1-(800) 589-0841 (phone)
How to Apply:
Select one of the links below to download the application or go to the program site for more information on how to apply. Once you fill out your application, send it to the address on the application. Do NOT send it to RxResource.
Select one of the links below to download the application or go to the program site for more information on how to apply. Once you fill out your application, send it to the address on the application. Do NOT send it to RxResource.
Eligibility:
Patient must be a US resident and have a gross annual household income at or below 200% Federal Poverty Level for all eligible products. with the exception of Megace ES which is set to 300% Federal Poverty Level. Additionally, Patient must not have any prescription coverage for the requested medication through any private or government funded prescription programs, including Medicare, Medicaid and Medicare Part D.
Patient must be a US resident and have a gross annual household income at or below 200% Federal Poverty Level for all eligible products. with the exception of Megace ES which is set to 300% Federal Poverty Level. Additionally, Patient must not have any prescription coverage for the requested medication through any private or government funded prescription programs, including Medicare, Medicaid and Medicare Part D.
Other Information:
Enrollment can be initiated by Patients, Physicians, and Patient Advocates by calling the toll free support line or by faxing or mailing in the completed enrollment application. Required Documentation - Patient and Physician must provide a completed enrollment application with both the patient and Healthcare professional signatures and dates. Proof of gross annual household income is required. Acceptable documents include: Federal Income Tax (form 1040 or 1040EZ) with appropriate schedules (C and/or F) or Federal Income Tax Form 1099 or Yearly benefits statement (SSA, 1099, etc), award letter or bank statements showing automatic deposit for the current calendar year or current pay stub. (at least three) For qualified patients, medication will be shipped directly to their Healthcare Provider's Office. Please allow 5 - 7 business days.
Enrollment can be initiated by Patients, Physicians, and Patient Advocates by calling the toll free support line or by faxing or mailing in the completed enrollment application. Required Documentation - Patient and Physician must provide a completed enrollment application with both the patient and Healthcare professional signatures and dates. Proof of gross annual household income is required. Acceptable documents include: Federal Income Tax (form 1040 or 1040EZ) with appropriate schedules (C and/or F) or Federal Income Tax Form 1099 or Yearly benefits statement (SSA, 1099, etc), award letter or bank statements showing automatic deposit for the current calendar year or current pay stub. (at least three) For qualified patients, medication will be shipped directly to their Healthcare Provider's Office. Please allow 5 - 7 business days.
Product(s) covered by program:
- Megace ES®
- Nascobal®
- Oravig®
- Zuplenz®
