The Auxilium Patient Assistance Program has been established to offer Auxilium medications to needy patients at no charge. Approval for participation in the program is granted according to guidelines established and administered by an independent board, independent of Auxilium. The Board reserves the right at any time and for any reason to discontinue, suspend, or otherwise revise the aid or assistance under the Program.

Your healthcare provider is an important factor in your ability to participate in the Program. Your healthcare provider is your sponsor for the Program and will monitor your medication while you are in the Program. The healthcare provider must complete and sign the appropriate section of the application before your request can be processed. On the application, you and your healthcare provider must both certify that you have no government or private insurance that would cover the full or partial cost of this medication. If approved, the medication will be provided free of charge, via the physician, sufficient for six months of therapy. Patients receiving Medicare Part D are not eligible to participate in Auxilium Pharmaceuticals’ Patient Assistance Program.

In order to apply to participate in the Program, the Patient Assistance Program Application must be completed and submitted for consideration. This is a voluntary Program and you are under no obligation to participate or provide the requested information.

In order to process the application, it must be complete and legible. If something does not apply or the answer is none, please write "N/A" or "None." All completed applications must be mailed to the address on the top of the application.