6900 College Blvd. Ste 1000 • Overland Park, KS 66211
Phone: 1-877-ASAP102 (1-877-272-7102) • Fax: 1-877-801-0777
Please ensure that the application is fully completed and that all supporting documentation is included. Incomplete or missing documentation may result in delays in processing the application.
Please include the following documentation when submitting this application for consideration into the ASAP program:
You may fax the application to 1-877-801-0777 or mail it to:
Allos Support for Assisting Patients
c/o AccessMED, Inc.
6900 College Blvd. Ste 1000
Overland Park, KS 66211
Please call 1-877-ASAP102 (1-877-272-7102) if you have any questions regarding the application or the ASAP program.
ASAP Reimbursement Counselor
Allos Therapeutics, Inc. does not guarantee coverage and/or reimbursement for FOLOTYN (pralatrexate injection). Coverage, coding, and reimbursement policies vary significantly by payer, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payers following the receipt of claims. Allos strongly recommends verifying coverage, coding, and reimbursement guidelines on a payer and patient-specific basis.
IMPORTANT SAFETY INFORMATION
Warnings and Precautions
Use in Specific Populations