Drug Information
Drug	Maxair Autohaler 14g
Generic Equivalent	pirbuterol acetate
Class	bronchodilator
Topic	Pulmo
Program Contact Info / Application Submission
Program	Graceway Pharmaceuticals Patient Assistance Program
Company	Graceway Pharmaceuticals
Form	Download PDF
Address	PO Box 8202, Somerville, NJ 08876
Phone	866-628-6498
Fax	866-838-5820
Website	http://www.chestervalleypharma.com/
Program Requirements
Details	Insurance card NOT required Drivers license NOT required Proof of Income required Copy of most recent tax return such as 1040, 1099 required as proof of income Letter from Doctor stating zero income required as proof of income Form 4506T (If taxes were not filed) NOT required as proof of income Most recent bank statements required as proof of income Most recent check/check stub copy required as proof of income Letter from employer NOT required as proof of income Benefits statement for Social Security, Unemployment, Veterans Benefits, Pension/Retirement required as proof of income Award Letter for Alimony/Child Support, Unemployment required as proof of income Notarized statement from patient stating zero income NOT required as proof of income
Delivery of Medication
Ship Time	4-5 weeks
Delivery Options	Can NOT be delivered directly to the patient Can be delivered directly to the doctor
Application Process
New Applications	New applications accepted Patients can apply directly to the program Doctors can apply directly to the program Advocates can apply directly to the program Can NOT apply for a new application via phone Can apply for a new application via fax Can apply for a new application via mail
Refills	Refills accepted Patients can apply for refills Doctors can apply for refills Advocates can apply for refills Can NOT apply for refills via phone Can apply for refills via fax Can apply for refills via mail
Re-Applications	Re-Applications NOT accepted Patients can NOT apply for Re-Applications Doctors can NOT apply for Re-Applications Advocates can NOT apply for Re-Applications Can NOT Re-Apply via fax Can NOT Re-Apply via mail
Appeals	Income Appeals NOT accepted Hardship Appeals NOT accepted Can NOT apply for an appeal via fax Can NOT apply for an appeal via mail
Eligibility
Limitations	Patients may be eligible if LIS is denied on a case by case basis Patients are eligible with existing prescription coverage Patients are eligible if prescription is not covered Patients may be eligible if prescription coverage has been exhausted on a case by case basis Patients are eligible if they are accepting Medicare Patients are eligible if they are accepting Medicare part D Patients are NOT eligible if the medication is not covered under Medicare Patients may be eligible if Medicare coverage has been exhausted on a case by case basis
Appeals
Conditions	Appeals may be consider out-of-pocket expenses on a case by case basis Appeals may be consider total medical expenses on a case by case basis Appeals must be made after the patient has been denied
Other Medications
Other  Medications  available in  this program	Maxair Autohaler 14g - bronchodilator Pulmo (Generic: pirbuterol acetate) Zyclara Cream 3.75% - (Generic: ) Estrasorb Topical Emulsion 1.74g - (Generic: )