Microsoft word - program procedures 2005.doc

To provide 3M Pharmaceuticals prescription medications to those individuals who are
not covered by a third-party prescription insurance plan, do not qualify for government
assistance, and whose income and medical expenses meet the qualifications of the 3M program.
Program Address: Program

Products Covered:
™ (imiquimod) Cream 5%, box of 12 packets
MetroGel-Vaginal (metronidazole vaginal gel), 0.75% Vaginal Gel
Minitran™ (nitroglycerin) Transdermal Delivery System – (0.1mg/hr, 0.2mg/hr, 0.4mg/hr, & 0.6mg/hr)
Tambocor™ (flecainide acetate) Tablets

Patient must meet all qualifications listed below and complete a new application for each request
for medication.
• Patient must not have private medical insurance for prescription drug coverage and must not qualify for any government (state or federal) assistance with his/her prescription medications. • Patient’s income is at or below 200% of the U.S. Federal Poverty Level. Medical and prescription expenses are taken into consideration when financially qualifying for our program. • Extenuating circumstances beyond the patient’s control must exist in which purchase of needed medicines imposes unreasonable hardship. • Patient must be a United States Resident with a Social Security Number.
All applications must have a prescription attached and are reviewed and considered on a case-
by-case basis. If you have questions regarding the program qualifications, please call us at 1-
Applications may be requested by calling our Customer Service Center at 1-800-328-0255; select
option 1. The information required at the time of application is as follows:

• Licensed prescriber’s first and last name • Prescriber’s degree • Prescriber’s shipping address (cannot be a P.O. Box) • Prescriber’s phone number and fax number • Patient’s first and last name • Patient’s date of birth
To get additional medication for a patient who has already received medication from our
company, another application must be requested and completed (do not photocopy a previously
requested application)
. If a reproduction of an application is received, a new application will
be sent to the practitioner, adding more time to the process.
Applications will be sent to the practitioner for his/her signature and State License Number. The
patient is required to fill in all patient information and sign the application for all requests. Each
application is patient specific and should not be altered for other patients’ use. A 3M
Pharmaceuticals application must be completed by the patient and practitioner each time a
patient needs additional medication. This is necessary to provide a unique order number
for every application prior to shipping the requested medications. Photocopies of
previously submitted applications will not be processed.

Once the signed application and prescription are received by fax or mail and approved by our
company, the order of medication will be shipped to the practitioner’s office for dispensing to the
Amount dispensed for new patients:
MetroGel-Vaginal: One 70 gram tube with applicators Minitran:
Amount dispensed for renewal patients:
MetroGel-Vaginal: One 70 gram tube with applicators Minitran:


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