Patient Assistance Programs

 

 

1. 3M Pharmaceuticals Patient Assistance Program

 

Pharmaceutical Company

3M Pharmaceuticals

Program Name

3M Pharmaceuticals Patient Assistance Program

Program Address

3M Center Bldg. 275-6W-13
St. Paul, MN 55144

Medicines On Program

Aldara cream, Maxair Autohaler, Metrogel-Vaginal .075%, Vaginal Use, Minitran transdermal delivery system, Norflex tablets, Norgesic Forte, Norgesic tablets, Tambocor

Phone Number

800-328-0255, opt 1

Guidelines and Notes

Patient must have no prescription coverage for any medications, be ineligible for any state or federal assistance, and not be able to buy the medication. Physician should only refer patient's whose income, in their judgement, is so low that purchasing the medication is causing unreasonable hardship. Patient's income should be below 200% of the Federal Poverty Level.

Initiating
Enrollment

Physician's office or social worker must call for Authorization Form with: prescriber's name, phone, degree, address, patient's name and medication /strength needed. The Authorization Form is patient specific and can't be copied, the form is faxed to the doctor's office. The completed form can be faxed or mailed back.

Health Provider's Role

The physician fills out a section, gives state license number and signs the form.

Patient's Role

Patient provides income, household size, insurance, medical and prescription expense information and sign the form.

How Dispensed

Sends medicine to physician or to a specified pharmacist at a hospital or health care entity.

Amount Dispensed

Varies according to product -- Aldara: 4 box of 12 packets; Maxair Autohaler: 3 inhalers; MetroGel Vaginal Cream: one 70 gm tube; Minitran: 120 patches (4 mos. supply); All tablets: 300 tablets.

Refills

The patient can call for refills. Every three months a new application is needed.

Limit

Indefinitely

 

2. AAI Pharma Inc

 

Pharmaceutical Company

AAI Pharma Inc.

Program Name

AAI Pharma Assists

Program Address

PO Box 124
Somerville, NJ 08876

Medicines On Program

AquaSol A , AquaSol E Drops, Azasan, Brethine Solution for Injection, Brethine Tablets, Darvocet A500, Darvocet-N 50, Darvon Compound-32, Darvon Compound-65, Darvon-N, 100mg, M.V.I Pediatric, M.V.I-12

Phone Number

866.224.0099

Guidelines and Notes

The patient must be a US resident with no private or public prescription coverage. The patient must also be at or below 120% of the Federal Poverty Guideline and a US resident.

Initiating
Enrollment

Anyone can call for an application and it will be automatically faxed out. The blank application can be copied. The completed application must be mailed back.

Health Provider's Role

The doctor must fill in a section and sign the application.

Patient's Role

The patient must fill in a section, sign the application and attach proof of income.

How Dispensed

The patient is sent a pharmacy card that must be taken to the pharmacy. The patient must pay a $10 co-pay for each prescription filled.

Amount Dispensed

The prescription can be written for up to a 3 month supply at a time.

Refills

After six months an re-order application is required to continue card activation. Once a year a new application with documentation is needed. The same applicaition is used for initail enrollment, annual enrollment and for Re-Orders.

Limit

Indefinitely

 

3. Abbott Laboratories Patient Assistance Program

 

Pharmaceutical Company

Abbott Laboratories

Program Name

Abbott Laboratories Patient Assistance Program

Program Address

Pharaceutical Products Div.
Dept D-31C, J23
200 Abbott Park Rd.
Abbott Park, IL 60064

Medicines On Program

Biaxin, Calijex, Colchicine, Cylert, Depakene, Depakote ER Tabs, Depakote Tablets, Fero-Folic 500, Gengraf, Hytrin, Iberet Folic 500, Isoptin SR, K-Lor, K-Tab, Kaletra Oral Solution, Kaletra Tablets, Mavik, Norvir Oral Solution, Norvir Soft Gelatin, Omnicef, Synthroid, Tarka, Tricor, Zemplar

Phone Number

800-222-6885

Guidelines and Notes

Call 8.00am - 5.00pm CST. Patient's must be under the current Federal Poverty Guidellines, have no third party prescription coverage or state or federal help. NOTE: The list of medications is unclear because a medication may not be noted as on the program but is handled case by case. Have a doctor call in for a medication if it is not on the list. On the same note: some medications on the list are special case only.

Initiating
Enrollment

Licensed prescriber or nurse must call for the application. Application can be copied. Completed application may be faxed with documentation.

Health Provider's Role

Doctor completes and signs, cannot be a stamped signature. No prescription needed.

Patient's Role

The patient needs to fill out a section, sign and attach proof of income for all members of the household.

How Dispensed

Sends medicine to doctor's office in about 2 weeks.

Amount Dispensed

3 month supply.

Refills

The doctor's office needs to call for refills about a month before medication runs out. If more medication is needed after the eligibility period has ended a re-enrollement application will be sent to the doctor's office. After a year, patient must completely reapply.

Limit

Indefinite

 

4. Abbott Virology Patient Assistance Program

 

Pharmaceutical Company

Abbott Laboratories

Program Name

Abbott Virology Patient Assistance Program

Program Address

D-31C, J23
200 Abbott Park Road
Abbott Park, IL 60064-6161

Medicines On Program

Kaletra, Norvir

Phone Number

800-222-6885, opt #2

Guidelines and Notes

The patient cannot have insurance that covers the medication, and not be eligible for any public assistance. For Kaletra, the patient must also meet financial guidelines that are not disclosed

Initiating
Enrollment

Someone from the doctor's office must call for an application. The blank application can be copied. The completed application can be faxed or mailed back.

Health Provider's Role

The doctor must fill out a section of the application and sign.

Patient's Role

The patient must fill out a section of the application and sign.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The medication is sent in a 3 month supply.

Refills

The doctor's office must call for refills 3 weeks before the current supply runs out. After a year a new application is needed.

Limit

Indefinitely

 

5. Access for Humatrope

 

Pharmaceutical Company

Eli Lilly & Company

Program Name

Access for Humatrope

Program Address

Humatrope Reimbursement Center
100 Grandview Rd., Suite 210
Braintree MA 02184

Medicines On Program

Humatrope 5mg vial, HumatroPen Injection Device 12mg Cart., HumatroPen Injection Device 24mg Cart., HumatroPen Injection Device 6mg Cart.

Phone Number

800-642-2340

Guidelines and Notes

The program acts as an advocate for the patient and tries to uncover another source for payment. If that fails, the program provides the drug free of charge or with a co-pay, as determined by consideration of patient/household income information. This is a last resort. The program is based on guidelines which are not released.

Initiating
Enrollment

Anyone can call for an application, but they prefer a doctor's office to call. Or it can be downloaded from www.humatrope.com. The completed application can be faxed back.

Health Provider's Role

The physician fills outs sections of the application including diagnosis, device and authorization. The phyisican must also sign the application.

Patient's Role

The patient must provide basic information and provide insurance information. The patient must also provide the most recent 10-40.

How Dispensed

Either makes arrangement for a home care provider to receive and administor, or sends drug to referring endocrinologist.

Amount Dispensed

The medication is sent out in three month supply.

Refills

Depending on who ships the medication, the refill procedure is different. Most will call the patient to get information for refills. Every nine months the case is reopened and the company contacts the patient for renewel.

Limit

Indefinitely

 

 

 

 

6. Aciphex Patient Assistance Program

 

Pharmaceutical Company

Janssen & Eisai, Inc

Program Name

Aciphex Patient Assistance Program

Program Address

PO Box 220458
Charlotte, NC 28222-0458

Medicines On Program

Aciphex

Phone Number

800-523-5870

Guidelines and Notes

Program is a joint venture between Eisai and Janssen Pharmaceuticals. Each case is dealt with on an individual basis- all benefits are verified for any insurance. Patients can have some insurance, there is no hard rules about coverage. The patient must also fall under financial guidelines that are not disclosed. Call between 9-5 Eastern Time weekdays.

Initiating
Enrollment

Anyone can call for an application, and it will be faxed out. The blank application can be photocopied. The completed application can be faxed back to the company.

Health Provider's Role

The physician completes a section, signs it and notes whether this is re-application or a new application.

Patient's Role

The patient must also fill out a section and sign it. The patient must also attach proof of income.

How Dispensed

The medication is sent to the physician's office.

Amount Dispensed

The medication is sent in a 30 day supply of 20 mg tablets.

Refills

the company will automatically will ship for six months as long as the prescription has the refills. Patient must reapply every 6 months.

Limit

Indefinitely

 

 

7. Acthar Gel Patient Assistance Program

 

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Acthar Gel Patient Assistance Program

Program Address

C/O NORD
PO Box 1968
New Fairfield, CT 06812-1968

Medicines On Program

Acthar Gel

Phone Number

1-800-459-7599

Guidelines and Notes

Eligibility is based on income and lack of prescription coverage. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assistance up from 25%-100% for one year.

Initiating
Enrollment

Anyone can call to start the process an application can be mailed to patient, doctor or social worker. The completed application can be faxed back to NORD.

Health Provider's Role

The doctor completes a section, signs and attaches a prescription to the application.

Patient's Role

Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the form.

How Dispensed

The medication is sent either to the doctor's office or a pharmacy.

Amount Dispensed

Depends on amount awarded to patient.

Refills

A new application is needed once a year.

Limit

Indefinitely

 

 

 

 

8. Actimune & Infergen Patient Assistance Program

Pharmaceutical Company

InterMune Pharmaceuticals

Program Name

Actimune & Infergen Patient Assistance Program

Program Address


PO Box 4280
Gaithersburg, MD 20885

Medicines On Program

Actimmune

Phone Number

800-577-9112

Guidelines and Notes

Patients must have either Chronic Granulomatous Disease or Osteopetrosis Disease. The patient must meet certain financial guidelines which are not disclosed.

Initiating
Enrollment

They no longer send out applications. Anyone can call for a pre-screening, then a patient specific application is sent to the doctor's office.

Health Provider's Role

Doctor provides proof of diagnosis of chronic granulomatous disease and can write a prescription for up to a year. The doctor must also sign the application and attach a copy of the state license.

Patient's Role

Patient must fill out a section of the application, sign and attach proof of income.

How Dispensed

Sends medicine to the doctor's office or the pharmacy.

Amount Dispensed

3 months supply at a time.

Refills

The doctor's office must call the company two weeks prior to running out of medication, and a new shipment will be sent out. Once a year a new application is needed.

Limit

Indefinite

 

 

9. Aggrastat Patient Assistance Program

 

Pharmaceutical Company

Merck & Company , Inc.

Program Name

Aggrastat Patient Assistance Program

Program Address

PO Box 222137
Charlotte, NC 28222-2137

Medicines On Program

Aggrastat

Phone Number

877-810-0595

Guidelines and Notes

It's a product replacement program, a hospital social worker usually applies after an uninsured patient is treated with the drug. The patients who are completely uninsured and meet financial guidelines.

Initiating
Enrollment

Hospital calls to get application. The blank application can be copied. The completed application is faxed back to the company.

Health Provider's Role

Put doctor's name on application; authorized hospital representative signs it. (usually social worker). Pharmacy dispensing record and drug invoice must be sent in with application.The NDC number must appear on the invoice.

Patient's Role

Patient's name, Social Secuirty Number, address and date of birth is needed. Financial documents must be provided on behalf of the patient.

How Dispensed

Sent to hospital or facility to reimburse them for product used.

Amount Dispensed

Full trays of medication are sent only.

Refills

n/a

Limit

Indefinitely

 

 

 

 

10. Agouron Patient Assistance Program

Pharmaceutical Company

Agouron Pharmaceuticals, Inc.

Program Name

Agouron Patient Assistance Program

Program Address

PO Box 230536
Centerville, VA 20120

Medicines On Program

Rescriptor, Viracept

Phone Number

888-777-6637

Guidelines and Notes

Patients must met in-house guidelines that they do not disclose. Patients must also apply to ADAP in order to apply for this program. If a patient is accepted into ADAP then the company will discontinue their assistance, usually after a month. The only times their will accept a fax of the application is in extreme cases such as rape. Other than that the application must be mailed in.

Initiating
Enrollment

Anyone can call to start the process with the patient's permission. All that is needed is the doctor's name, address, DEA number, phone number and the patient's phone number and name. The company then mails a patient specific application to the doctor's office.

Health Provider's Role

The doctor must fill out section 1 of the application. A prescription for a four month supply must also be attached.

Patient's Role

Patient must fill out section 2 of the application and include TWO pieces of documentation of their proof of income. The patient must also show proof that they have applied to ADAP as well.

How Dispensed

Medication is sent to the doctor's office, within 2-3 days.

Amount Dispensed

Medication is sent out in one month supply.

Refills

After 18-21 days a new shippment is automatically sent out. Every three months a new application and new prescription is needed. Finanical documents are only needed once a year.

Limit

Indefinite

 

11. Alcon Cares Patient Assistance Program

 

Pharmaceutical Company

Alcon Labs

Program Name

Alcon Cares Patient Assistance Program

Program Address

Not Applicable

Medicines On Program

Azopt 1% (15 ml btl), Betoptic S 0.25% (15 ml btl), Bion Tears, Brimonidine Tartate 0.2% (15ml btl), Carteolol HCL 1% (10 ml btl), Ciloxan Ointment (3.5 g tube), Ciloxan Solution (5 ml btl), Cipro HC Otic (10 ml btl), Ciprodex (7.5 ml btl), Dipivefrin HCL 1% (15 ml btl), Econopred Plus (10 ml btl), Flarex (5 ml btl), Iopidine 0.5% (10 ml btl), Isopto Carbachol 1.5% (30ml btl), Isopto Carbachol 3% (30 ml btl), Isopto Carpine 1% (15 ml btl), Isopto Carpine 2% (15 ml btl), Isopto Carpine 4% (15 ml btl), Levolbunolol HCL .5% (10 ml btl), Maxitrol Suspension (5 ml btl), Metipranolol Solution 0.3% (10 ml btl), Pilopine HS 4% Gel (4 g tube), Systane, Tears Naturale Forte, Tears Naturale Free Lubricant Eye Drops, Tears Naturale PM Ointment, Timolol Malcate Gel 0 .5% (5 ml btl), Timolol Maleate Gel 0.25% (5 ml btl), Timolol Maleate Solution 0.25% (15 ml btl), Timolol Maleate Solution 0.5% (15 ml btl), TobraDex Ophthalmic Ointment (3.5 g tube), TobraDex Suspension (10 ml btl), Travatan 0.004% (2.5 ml btl), Unisol 4 Saline, Vexol (10 ml btl), Vigamox (3ml btl)

Phone Number

800-222-8103, opt 2

Guidelines and Notes

This program is open to patients being treated by a US licensed physician who feels the patient cannot afford the medication. The patient also must have no prescription insurance coverage and does not qualify for any public perscription programs. The patient's annual income must be at or below $18,000 for single person, $25,000 for a family of 2 and $36,000 for a family of 4.

Initiating
Enrollment

The doctor can call for the application and it will be sent out. The blank application can be copied. The completed application can be faxed back.

Health Provider's Role

The doctor must fill out a section of the application and sign it.

Patient's Role

The patient must sign the application.

How Dispensed

Prescription medications are sent to the doctor's office, but over the counter medications can be sent to the patient's house.

Amount Dispensed

Over-the-counter medications and Glaucoma medications are sent in a 6 month supply. The amount of the perscription medicine sent depends on the need.

Refills

To get another supply another application is needed. For over-the-counter medicines the limit is one 6 month supply a year.

Limit

Indefinitely.

 

12. Allergan Patient Assistance Program

 

Pharmaceutical Company

Allergan, Inc.

Program Name

Allergan Patient Assistance Program

Program Address

PO Box 1003
Wayne NJ, O7474-9928

Medicines On Program

Alphagan P 0.15% 10 ml, Betagan .25% B.I.D. ,15ml, Betagan .5% B.I.D. ,15ml, Celluvisc, Lumigan .03% Q.D., 7.5 ml, Refresh Liquigel, Refresh Plus, Refresh PM, Refresh Tears, Restasis .05%, 32x.4ml, Tazorac Cream 0.05%, Tazorac Cream 0.1%, Tazorac Gel 0.05%, Tazorac Gel 0.1%

Phone Number

800-553-6783

Guidelines and Notes

The patient must have no prescription coverage, and make less that $12,000 for a one or two person family, or less than $19,000 for a 3 or more family. There is a limit of 2 Over the Counter medications and 2 prescription medications per 6 months per patient.

Initiating
Enrollment

Anyone can call for the application or get it off the website. The completed application must be mailed back.

Health Provider's Role

The doctor must fill out a section and sign the application.

Patient's Role

The patient fills out a section on the application and signs it as well.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

A six month supply is sent to the office, to be given to the patient in whatever dosage seems fit.

Refills

The last week of the 5th month, a new application should be mailed to the company.

Limit

Unspecified

 

13. Amgen Safety Net Foundation for Kineret

 

Pharmaceutical Company

Amgen, Inc.

Program Name

Amgen Safety Net Foundation for Kineret

Program Address

c/o InTeleCenter, 9th Floor
PO Box 4280
Gaithersburg, MD 20897

Medicines On Program

Kineret

Phone Number

1-866-546-3738

Guidelines and Notes

The patient must be US resident, can not have insurance that covers prescriptions, doesn't cover injectables, or the insurance has reached a cap. The patient may have Medicaid with a spend down that they are unable to met. The company will also send out one free SimpleJect Device to aid patients in the injection, if needed.

Initiating
Enrollment

Anyone can call for an application, it will faxed out. The blank application can be copied. A completed application can be faxed back.

Health Provider's Role

The physician must fill one page of the application, and sign it. The physician must attach a prescription made out for one year. If the patient needs the SimpleJect Device, a second prescription must be written.

Patient's Role

Must fill out 2 pages of the application, including information about annual gross income, sources of income and sign the application in two places.

How Dispensed

The medication will be sent to the doctor's office or the patient's house. But someone must sign for the medication.

Amount Dispensed

The medication will be sent out in 2 month supplies.

Refills

The medication will be automatically sent out until the end of the year, when a whole new application. The company will send out a renewal application about 1 month before the year ends.

Limit

Not Applicable

 

14. Arch Foundation Patient Assitance Program for Mirena

 

 

Pharmaceutical Company

Arch Foundation

Program Name

Arch Foundation Patient Assitance Program for Mirena

Program Address

P.O. Box 220908
Charlotte NC, 28222-0908

Medicines On Program

Mirena

Phone Number

877.393.9071

Guidelines and Notes

This is a program for patients who have no insurance for birth control (Mirena is an IUD). The patient must be a US resident who is being treated by a US licensed health care provider. The company does have financial guidelines but they are not disclosed. While the company will pay for the IUD, it does not pay for inseration services or removal services.

Initiating
Enrollment

Anyone can call for an application The blank application can be copied. The completed application can be mailed or faxed back to the company

Health Provider's Role

The health care provider must fill out a section and sign the application. The doctor who will be inserting the device must also sign the application.

Patient's Role

The patient must fill out a section about insurance and financial information and sign the application.

How Dispensed

The Mirana is sent to the clinic to be placed, it is sent in 3-5 buisness days.

Amount Dispensed

Not Applicable

Refills

Not Applicable

Limit

Not Applicable

 

15. Aricept Assistance Program

 

Pharmaceutical Company

Pfizer, Inc.& Eisai

Program Name

Aricept 10 mg Tablets, Aricept 5 mg Tablets

Program Address

1480 Arthur Ave, Ste D
Louisville, CO 80027

Medicines On Program

Aricept 10 mg Tablets, Aricept 5 mg Tablets

Phone Number

800-226-2072

Guidelines and Notes

Patient must be a US resident and meet financial guidelines that are not disclosed. The patient must also be getting care on an out patient basis only

Initiating
Enrollment

It is preferred that the doctor call for the qualifying application or re-qualifying application, which will be faxed out. The blank applications can be photocopied. The completed application can be faxed or mailed back.

Health Provider's Role

Doctor completes a section and signs it. Prescription is incorporated into the application.

Patient's Role

Patient or power of attorney must sign the application.

How Dispensed

Medicine is sent to doctor's office.

Amount Dispensed

3 month supply.

Refills

The doctor calls to request Requalification Form when patient starts the last 30 tablets. After a year a whole new application is needed.

Limit

Indefinite

 

16. Arixtra Reimbursement Services

Pharmaceutical Company

Sanofi-Synthelabo Pharmaceuticals, Inc.

Program Name

Arixtra Reimbursement Services

Program Address


Not Applicable

Medicines On Program

Arixtra

Phone Number

866-274-9872, opt 5

Guidelines and Notes

The patient cannot have any prescription coverage for the medication and must meet financial guidelines that are not disclosed.

Initiating
Enrollment

Anyone can call for application and it will be faxed out. The blank application can be copied.

Health Provider's Role

The doctor must fill out a section and sign the application.

Patient's Role

The patient must fill out a section and sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

One dosage, usually a week, is sent out.

Refills

This is usually a one time medication, but if more medication is needed then a new application is required.

Limit

See Above.

 

17. Astra Zeneca Foundation Patient Assistance Program

 

Pharmaceutical Company

Astra Zeneca Pharmaceuticals

Program Name

Astra Zeneca Foundation Patient Assistance Program

Program Address

PO Box 66551
St. Louis, MO 63166-6551

Medicines On Program

Accolate Tablets 10 mg, Accolate Tablets 20 mg, Atacand HCT Tablets 16/12.5mg, Atacand HCT Tablets 32/12.5mg, Atacand Tablets 16 mg, Atacand Tablets 32 mg, Atacand Tablets 8 mg, Crestor Tablets 10mg, Crestor Tablets 20mg, Crestor Tablets 40mg, Crestor Tablets 5mg, Emla Cream 5% tube, Entocort EC Capsules 3 mg, Nexium DR Capsules 20 mg, Nexium DR Capsules 40 mg, Plendil Tablets 2.5 mg, Plendil Tablets 10 mg, Plendil Tablets 5 mg, Pulmicort Respules .25mg/2mL, Pulmicort Respules 0.5mg/2mL, Pulmicort Turboinhaler 200 mcg, Rhinocort Aqua Nasal Spray 32 mcg, Seroquel Tablets 200 mg, Seroquel Tablets 25 mg, Seroquel Tablets 300 mg, Toprol XL Tablets 100 mg, Toprol XL Tablets 200 mg, Toprol XL Tablets 50 mg, Zoladex 10.8 mg Depot every 3 months, Zoladex 3.6 mg Depot monthly

Phone Number

800-424-3727

Guidelines and Notes

Patients must be US citizens with a valid Social Secruity number and have an annual income below $18,000 per individual or $24,000 for couples. For information about status of mailed prescription call 800-698-0085. They are often backlogged and ask that someone calls to check the patient's status before sending in an application or reapplication. For Oncology medications, see Astra Zeneca Foundation Patient Assistance Program for Oncology.

Initiating
Enrollment

The application can be downloaded from their website (http://www.astrazeneca-us.com/pap/) or call the above number Completed application should be mailed back to the company.

Health Provider's Role

Doctor completes and signs a section of the application. A prescription must be attached or fill out the prescription information on the appilcation.

Patient's Role

The patient must fill out the patient section and sign it. They must also attach proof of income and either a denial letter from Medicaid or a copy of the Medicaid card.

How Dispensed

The medication can be sent to either the patient or the doctor.

Amount Dispensed

A three month supply.

Refills

20 to 30 days before the medication runs out, the patient must call the number on the medication bottle for a refill. Totally new applications needed once a year. A re-application is sent 45 days prior to one year expiration date.

Limit

Indefinitely

 

 

 

 



18. Astra Zeneca Foundation Patient Assistance Program for Oncology

 

Pharmaceutical Company

Astra Zeneca Pharmaceuticals

Program Name

Astra Zeneca Foundation Patient Assistance Program for Oncology

Program Address

PO Box 66551
St. Louis, MO 63166-6551

Medicines On Program

Arimidex Tablets, 1 mg, Casodex Tablets 50 mg, Faslodex 2.5 mL (1 month injection), Faslodex 5 mL (1 month injection), Nolvadex Tablets 10 mg

Fax Number

Not Applicable

Guidelines and Notes

This phone number is for the Cancer Support Network through Astra Zeneca. This program is the same as the Astra Zeneca Foundation Patient Assistance Program except the process is much faster for the oncology medications. This program also tries to find funding for the patient before using the patient assistance component.

Initiating
Enrollment

Anyone can call for an application and they will fax it out. The blank application is the same as the application for the Astra Zeneca Foundation but call the above number to get fax numbers to rush the process.

Health Provider's Role

Doctor completes and signs a section of the application. A prescription must be attached or fill out the prescription information on the appilcation.

Patient's Role

The patient must fill out the patient section and sign it. They must also attach proof of income and either a denial letter from Medicaid or a copy of the Medicaid card.

How Dispensed

The medication can be sent to either the patient or the doctor.

Amount Dispensed

A three month supply.

Refills

20 to 30 days before the medication runs out, the patient must call the number on the medication bottle for a refill. Totally new application needed once a year. A re-application is sent 45 days prior to one year expiration date.

Limit

Indefinitely.

 

19. Aventis Behring Patient Assistance Program

Pharmaceutical Company

Aventis Behring

Program Name

Aventis Behring Patient Assistance Program

Program Address

1020 First Ave.
King of Prussia, PA 19406

Medicines On Program

Gammar-PIV, Helixate 8FS, Humate-P, Monoclate-P, MonoNine, Stimate, Zemaira

Phone Number

800-676-4266

Application

Contact program for application

Guidelines and Notes

This program has some specific guildelines that are not disclosed. Since drugs availability changes based on inventory, call if drug needed is not on list. The list is also subject to change.

Initiating
Enrollment

Anyone can call to start the process, they take information over the phone and send a patient-specific application. The completed application must be mailed back.

Health Provider's Role

The provider must complete a section of applicaiton and attach an original prescription. Information needed includes history of treatment. Provider will also have to make a case for why patient needs assistance.

Patient's Role

The patient must provide basic financial, and insurance information and sign a section of the application.

 

 

How Dispensed

The medication will be sent to a licensed site.

Amount Dispensed

Usually the medication is sent out in a 3 month supply.

Refills

Every three months the patient must be reevaluated, and a new application is needed.

Limit

not specified

 

20. Aventis Oncology Pact+ Program

 

Pharmaceutical Company

Aventis Pharmaceuticals

Program Name

Aventis Oncology Pact+ Program

Program Address

100 Grandview Rd. Ste 210
Braintree MA, 02184

Medicines On Program

Anzemet CINV injections, Anzemet CINV Tablets, Anzemet PONV injection, Anzemet PONV Tablets, Nilandron Tablets, Taxotere

Phone Number

800-996-6626 #1

Guidelines and Notes

For each drug there is a different application.(In NeedyMeds there are all together.) Patients who have no insurance, who are underinsured or have already received their maximum benefits may be eligible for alternative funding are eligible. Nilandron Tablets require patients to be below the Aventis Poverty Level (family of one below $17,960 per year, for family of 2 below $24,240 more details on application.)

Initiating
Enrollment

If a patient or doctor calls for application, they will take information make it patient specific, so have patient's chart ready. Blank applications are also available on www.aventisoncology.com. These applications can be copied. Completed applications can be faxed back except for Nilandron, which must be mailed back. The company will call to follow up on additional information and send out a patient consent form.

Health Provider's Role

The doctor must fill out a section including a signature and a DEA number. For Nilandron, the doctor must also send a prescription for upto a three month supply.

Patient's Role

The patient must provide medical, insurance and annual household income. For Nilandron, patient must also attach proof of income.

How Dispensed

Medication is sent to the doctor's office.

Amount Dispensed

Three cycles of treatment are supplied. The actual amount different depending on the medication.

Refills

Doctor complete a re-order form with is included with initial approval letter. Re-order is faxed and processed based on the product's treatment cycle. If the perscription has changed a new reorder must be completed. Once a year a new application is needed.

Limit

Indefinitely

 

21. Aventis Patient Assistance Program

 

Pharmaceutical Company

Aventis Pharmaceuticals

Program Name

Aventis Patient Assistance Program

Program Address

PO Box 759
Somerville, NJ 08876

Medicines On Program

Allegra 180 mg Tablets, Allegra 30 mg Tablets, Allegra 60mg Tablets, Allegra D 60 mg Tablets, Amaryl 1 mg Tablets, Allegra 180 mg Tablets, Allegra 30 mg Tablets, Allegra 60mg Tablets, Allegra D 60 mg Tablets, Amaryl 1 mg Tablets,

Phone Number

800-221-4025

Guidelines and Notes

Patients must be US residents who don't qualify for any government or private insurance for prescriptions. The patient's total annual income must be at or below 200% of the current Federal Poverty Guidelines.

Initiating
Enrollment

Anyone can call for a form, it will be faxed out. The application can be copied. The completed application must be mailed back to the company.

Health Provider's Role

Doctor completes, signs, and attaches a prescription for up to a 90 day supply (except Lantus which is provided in minimum of 4 vial supply for 6 month supply and in increments of 10).

Patient's Role

The patient must fill out a section, sign and attach a copy of federal tax income tax return. If no taxes were filed, some form of proof of income is required.

How Dispensed

Medication is sent to the doctor's office. The patient's name will be on the mailing label, not the bottle.

Amount Dispensed

Varies by medication. Usually a three month supply. Takes 4 weeks for them to process and send the medication.

Refills

Use an entirely new application, just like first time with a perscription, but proof of income is only needed once a year.

Limit

Unspecified

 

22. Axcan Assist Program

 

Pharmaceutical Company

Axcan-Scandipharm, Inc

Program Name

Axcan Assist Program

Program Address

PO Box 52065
Phoenix AZ, 85072-9152

Medicines On Program

Bentyl 10mg Tablets, Bentyl 20mg Tablets, Carafate Oral Suspension, Carafate Tablets 1 gm, Urso 250, Viokase 16 Powder, Viokase 16 Tablet

Phone Number

866-292-2679, opt 2

Guidelines and Notes

The patient must be at or below the Federal Poverty Guidelines, with no perscription coverage. If the patient has coverage but has capped it, then they are still eligible but have a co-pay of$3 to $18.

Initiating
Enrollment

Anyone can call to start the process. The person must have the patient's Social Secruity Number, insurance information, gross monthy income, number of dependants and the doctor's information. If the patient is approved at this step then a presumptive 30 day supply is sent to a pharmacy for the patient to pick up. Then a more detailed application is sent either to the patient or the doctor. This application is patient specific can can not be copied. The completed application must be mailed back.

Health Provider's Role

The doctor must fill out a section that includes their DEA# and prescription information and sign the application.

Patient's Role

The patient must provide detailed financial information and sign the application.

How Dispensed

A pharmacy card is sent to the patient to use once a month.

Amount Dispensed

11 months are allowed on the card.

Refills

After one year another application must be filled out.

Limit

Indefinitely

 

23. Bausch and Lomb Indigent Patient Program

 

Pharmaceutical Company

Bausch and Lomb

Program Name

Bausch and Lomb Indigent Patient Program

Program Address

PO Box 30450
Rochester, NY 14603-0450

Medicines On Program

Alrex, Lotemax

Phone Number

800-323-0000

Guidelines and Notes

Patients must be finacially disadvantaged and have no source of prescription drug coverage through private insurance or public assistance. The patient must have an annual household income of less than $9,000. for a single person or $14,000 for a combined family.

Initiating
Enrollment

Anyone can call for the application and it will be faxed out. The completed application must be mailed back to the company.

Health Provider's Role

The physican must fill out a section and include a prescription and a copy of the physician's current license.

Patient's Role

The patient only needs to tell the doctor they are in need.

How Dispensed

The medications are sent to the doctor's office.

Amount Dispensed

The company sends out three bottles at a time.

Refills

When the patient is down to the last bottle a whole new application is needed.

 

24. Baxter Factor Plus Program

 

Pharmaceutical Company

Baxter Healthcare Corporation

Program Name

Baxter Factor Plus Program

Program Address

PO Box 4280
Gaithersburg, MD
20885-4280

Medicines On Program

Advate, Feiba VH, Hemofil-M AHF, Recombinate rAHF

Phone Number

800-548-4448, #2

Guidelines and Notes

A patient must be a US resident, have no insurance and be in financial need. In order for a patient to enroll in the program the facility or provider must also be enrolled as well. Once a facility or provider is enrolled once they do not need to do so again. The application has 3 sections, including an enrollement for the facility. It also has a replacement application (Form D). To get replacement medication the form must sent in through out the month but not before the 20th of the next month. This is only good for Hemofil M AHF, Recombinate rAHF, or FEIBA VH.

Initiating
Enrollment

Once the facility has a Baxter Customer number someone from the facility or doctor's office must call for a patient application and it will be sent out. Both applications can be copied. The completed application can be faxed or mailed back.

Health Provider's Role

Form A is for the provider at the facility. It must be signed and dated, agreeing that the patient will be recieving the medication free of charge. Form C is for the phyisician to fill out at and sign. This form include a prescription sections.

Patient's Role

Form B is for the patient to fill out and asked for detailed financial and income information. The patient must sign the application.

How Dispensed

Medication is sent to facility or the stated address.

Amount Dispensed

The maximium amount of replacement product a provider may receive is based on the patient's hisorical average annual dose, not to exceed 80,000 units.

Refills

To get another supply fill out form D and sent in. Every year a new application is needed.

Limit

Indefinite

 

 

25. Bayer Patient Assistance Program

 

Pharmaceutical Company

Bayer Pharmaceuticals Corporation

Program Name

Bayer Patient Assistance Program

Program Address

PO Box 29209
Phoenix, AZ 85038-9209

Medicines On Program

Adalat CC, 30mg, Adalat CC, 60mg, Adalat CC, 90 mg, Avelox 400 mg, Avelox IV, Biltricide, Cipro 250mg, Cipro 500 mg, Cipro 750 mg, Cipro IV, Cipro XR, Domepaste Bandages, DTIC-Dome, Nimotop, Precose 100 mg, Precose 25mg, Precose 50 mg

Phone Number

800-998-9180, Opt 1

Guidelines and Notes

Patient must meet financial guidelines that re not disclosed. Patients cannot have prescription for the medications needed. Patient may also apply if the insurance has reached its cap.

Initiating
Enrollment

Anyone may call as long as long as the person has all the financial, expense, and doctor's information. The company takes most information over the phone and then sends the application to the doctor. They also supply the patient with a group number, ID number, and a process number so the patient can use them to get prescriptions in case of an emergency in the first 30 days. The completed application must be mailed back.

Health Provider's Role

Doctor signs and dates application. Company authorizes additional use of card (beyond 30 days) once application is received.

Patient's Role

Complete patient section of application and sign it.

How Dispensed

The company sends card with application for patient to bring to the pharmacy.

Amount Dispensed

Each application is good for up to six months.

Refills

After 6 months, a form is sent out that the doctor and patient needs to fill out and send back. After a new application is needed.

Limit

Indefinitely

 

26. Benefix Patient Assistance Program

 

Pharmaceutical Company

Genetics Institute, Inc.

Program Name

Benefix Patient Assistance Program

Program Address

5870 Trinity Parkway, Ste 600
Centerville, VA 20120

Medicines On Program

Benefix , ReFacto

Phone Number

888-999-2349

Guidelines and Notes

Patient must be uninsured and meet the following the financial guidelines: At or below $25,000 for a single person or $40,000 for a family. The company reviews each case individually. Amish patients are eligible for one year, non-Amish patient must reapply every three months.

Initiating
Enrollment

Have health care provider call company and they will send application to doctor's office or DME provider. The application is patient specific and can not be copied. Completed application can faxed back as long as the original is mailed in as well.

Health Provider's Role

Doctor fills out physician section and signs the application.

Patient's Role

Patient provide income information, household size and insurance information. Patient must also sign the application.

How Dispensed

Sent to physician's office.

Amount Dispensed

Depends on the request; up to 3 months. (The max is 75000 units per year.)

Refills

Patient must requalify for the program every 90 days (unless Amish who are enrolled for one year.)

Limit

Indefinitely

 

27. Berlex Oncology Camcare

 

Pharmaceutical Company

Berlex Laboratories

Program Name

Berlex Oncology Camcare

Program Address

PO Box 221289
Charlotte, NC 28222-1289

Medicines On Program

Campath 30 mg, Fludara 50 mg, Leukine Liquid 500mcg, Leukine Lyphilized 250 mcg

Phone Number

800-473-5832

Guidelines and Notes

Hrs. 8:30-5 pm M-F Patient must be uninsured and be US citizen and fall within income guidelines, which are not disclosed If patient has insurance but it doesn't cover these drugs, they must obtain proof of non-coverage and they will be considered on a case by case basis.

Initiating
Enrollment

Anyone can call for an application and it will be faxed out. The blank application can be copied. The completed application can be faxed or sent back.

Health Provider's Role

Doctor complete a section and signs the application.

Patient's Role

The patient needs to provide detailed financial information and documentation of lack of insurance. The patient also needs to sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The amount sent out varies depending on the medication and the patient's needs. Fludara - up to 6 shipments up to 5 vials per month. Campath - 1 to 4 boxes (3 ampules/box) per month. Leukine depends on how prescribed.

Refills

Doctor's office calls company to attest patient still in need and the refills are sent out. A new application is needed every six months.

Limit

Indefinite

 

28. Berlex Patient Assistance Program

 

Pharmaceutical Company

Berlex Laboratories

Program Name

Berlex Patient Assistance Program

Program Address

PO Box 1000 M2/1-5
Montville, NJ 07045-1000

Medicines On Program

Betapace 120 mg, Betapace 160 mg, Betapace 240 mg, Betapace 80 mg, Betapace AF 120 mg, Betapace AF 180 mg, Betapace AF 80 mg, Climara 0.025 mg, Climara 0.0375 mg, Climara 0.05 mg, Climara 0.06 mg, Climara 0.075 mg, Climara 0.1 mg, Climara Pro 0.045/0.015mg

Phone Number

888-237-5394, option 6, option 1

Guidelines and Notes

Patient must be a US citizen. The patient must also be in one of the two following situations: 1- have an income of $20,000 or less and not be eligible for Medicare, Medicaid or any private or state programs. 2- have a household income of $15,000 or less and be eligible for the above programs but not have prescription coverage. There are three different applications, one for each medication. All the information needed is the same. The Patient Consent Form must be signed by the prescriber. There is also a Doctor/Prescriber Enrollment Form that the doctor has to fill out the first time they have a patient enrolling in the program, but not for any future patients. Once a patient is accepted into the program the doctor/perscriber's office will be notified via US Mail. If the patient is not accepted, a denial letter with the reason for denial will be sent to the doctor's office via US Mail.

Initiating
Enrollment

They prefer that the doctor/prescriber's office start the process, but anyone can call for an application which will be sent to the doctor/prescriber's office. If a patient calls, have the doctor/prescriber's fax and phone number and the name of the person to whom the fax will be sent. The application can be copied. The completed application can be faxed or mailed back.

Health Provider's Role

Doctor completes and signs both the doctor/prescriber enrollment and patient enrollment forms. No stamps accepted. Most of the communications between the company and the office will be via fax.

Patient's Role

The patient must fill out the Patient Enrollment form with regards to Annual Gross Family Income and Martial Status, check all the appropriate boxes and sign the Patient Consent Form and provide proof of income.

How Dispensed

Medication is sent to the doctor/prescriber's office within a week to 10 days of acceptance. Please include street address and suite number as well as Post Office box for corrrespondence

Amount Dispensed

A three month supply is sent at one time.

Refills

A Quarterly Product Request form is sent to the doctor/perscriber's office that needs to be filled out for refills. If there has been a change to dose or strength a prescription must be included with the form. After a year, the doctor/prescriber's office will receive a new application that must be completely filled out with current information and signed by both patient and prescriber.

Limit

Indefinitely

 

29. Bertek Patient Assistance Program

 

Pharmaceutical Company

Bertek Pharmaceuticals, Inc.

Program Name

Bertek Patient Assistance Program

Program Address

PO Box 4310
Morgantown, WV 26504-4310

Medicines On Program

Clorpres, Maxzide, Maxzide-25 mg, Nitrek 0.2 mg/hr, Nitrek 0.4 mg/hr, Nitrek 0.6 mg/hr, Phenytek

Phone Number

888-823-7835

Guidelines and Notes

This program is designed to be a temporary program. Patients must be US citizens or documented legal aliens and not be eligible for Medicaid or any third party prescription coverage.The patient must also be within the Federal Poverty Guidelines. One page of the application is a Waiver and Release of Liability. This needs to be signed by the patient and two witnesses.

Initiating
Enrollment

Anyone can call for an application and it will be faxed out. The application can be copied. The completed application must be mailed back in.

Health Provider's Role

The doctor must complete a section, sign and attach a prescription.

Patient's Role

The patient must fill out a section, sign and attach a copy of proof of income. One page of the application is a Waiver and Release of Liability. This needs to be signed by the patient and two witnesses.

How Dispensed

The medication is sent to the doctor's office. Patients needing Clozaril, Ritalin LA and Focalin are sent a retail card which is taken to the pharmacy.

Amount Dispensed

The medication is sent out in a 90 day supply. FOr Clorpres, Maxzide and Phenytek requests will be filled with stock bottle of 100. For Nitrek, requests will be filled with stock bottle of 30.

Refills

A new prescription is need for refills. A whole new application with documentation is needed after one year.

Limit

Unspecified

 

30. Betaseron Foundation

 

Pharmaceutical Company

MS Pathways

Program Name

Betaseron Foundation

Program Address

MS Pathways
PO Box 221349
Charlotte, NC 28222

Medicines On Program

Betaseron

Phone Number

800-948-5777

Guidelines and Notes

The patient must be US resident and must meet financial guidelines that are not disclosed. The support program is very detailed including registered nurse counselors who are available 24 hours a day, seven days a week. They also provide training if needed. There is a co-pay for each shipment ranging from $5.00-$35 .00

Initiating
Enrollment

They prefer for the patient to call so they can get a lot of the information they need; if patient can't call, OK for relative or provider who knows patient to call. Patient is registered over the phone, and part of application is sent to the doctor and another part to the patient.

Health Provider's Role

Doctor completes, signs, and attaches a prescription.

Patient's Role

The patient must fill out a section on financial and insurance information, sign the application and attach proof of income.

How Dispensed

Sends the medication to address where patient will be able to sign for it (usually home or work). There is a co-pay for each shipment ranging from $5.00-$35.00

Amount Dispensed

A shipment of 30 days is sent.

Refills

To get a refill, the patient must call in when only 5 doses are left or the company will call. After one year a whole new application is needed.

Limit

Unspecified

 

31. Biovail Patient Assistance Program

 

Pharmaceutical Company

Biovail Pharmaceuticals, Inc.

Program Name

Biovail Patient Assistance Program

Program Address

PO Box 836
Somerville NJ 08876

Medicines On Program

Betaseron Foundation

Phone Number

866-268-7325

Guidelines and Notes

Patient must have already been enrolled and receiving Cardizem from the patient assistance program that was previously available through Aventis; no new applications will be accepted for any form of Cardizem. New patients can apply for Teveten and Zovirax. The patient must be a legal resident of the US. Patent can't have any third party coverage for prescriptions from public or private sources. Patient's household income must be less 200% of the federal poverty level. If you have questions, call between 9-5 pm EST.

Initiating
Enrollment

Call for form; they will automatically fax it. Completed application must be mailed back.

Health Provider's Role

Doctor completes a section, signs it, and attaches a prescription for a 3 month supply and indicates whether or not this is a new or refill application. For Zovirax one tube per request.

Patient's Role

The patient must fill out section as well, sign it and attach proof of income.

How Dispensed

Allow 4-6 weeks for approval of applictation. Medication will be delivered to practitioner's office.

Amount Dispensed

3 month supply.

Refills

Use same form and indicate that it is a repeat application.

Limit

Indefinitely, but they state they may discontinue the program at any time.

 

 

 

 

 

 

32. Blaine Patient Assistance Program

 

Pharmaceutical Company

Blaine Company, Inc.

Program Name

Blaine Patient Assistance Program

Program Address

PO Box 430
Hackettstown, NJ 07840

Medicines On Program

Mag-Ox 400 mg, Uro-Mag 140 mg capsule

Phone Number

800-503.7747

Guidelines and Notes

The patient must be a US resident, and meet financial guidelines that are not disclosed.

Initiating
Enrollment

Anyone can call for an application and it will be faxed out. An application can also be filled out on line at Rxhope.com The application can be copied. THe completed application can be faxed back to the company

Health Provider's Role

The doctor must fill out a section and sign it.

Patient's Role

The patient needs to provide information but a patient signature is not needed.

How Dispensed

The medication will be sent to the patient's house unless otherwise noted.

Amount Dispensed

The medication is sent in a four month supply.

Refills

The medication is sent out automatically sent out until the year is over and then a new application is needed.

Limit

Not Applicable

 

 

 

 

 

 

 

 

33. Boehringer Ingelheim Care Foundation Patient Assistance Program

 

Pharmaceutical Company

Boehringer Ingelheim Pharmaceuticals, Inc.

Program Name

Boehringer Ingelheim Care Foundation Patient Assistance Program

Program Address

c/o ESI/SDS
PO Box 66555
St. Louis MO 63166

Medicines On Program

Aggrenox, Atrovent Inhalation Aerosol, Atrovent Nasal Spray, Catapres-TTS Transdermal Patch, Combivent, Flomax Capsules, Micardis HCT, Micardis Tablets, Mirapex, Mobic, Viramune Oral Suspension, Viramune Tablets

Phone Number

800-556-8317

Guidelines and Notes

Income guidelines for this program is at 200% of the Federal Poverty Guidelines. Patient must be US citizen and resident, have no complete or partial prescription insurance coverage, and income must be at or below their guidelines.

Initiating
Enrollment

Anyone can call to start the process, but must be 18 years or older. The blank application can be copied.

Health Provider's Role

Doctor completes, signs, and fills out the prescription built into the application.

Patient's Role

The patient needs to provide prood of household income, and send in a tax return if filed. The patient must also sign the application.

How Dispensed

The company sends medicine to doctor's office in 2-3 weeks.

Amount Dispensed

The medication is sent out in up to a three month supply.

Refills

To get a refill send copy of application and refill prescription. Once a year a whole new application with proof income is needed.

Limit

Indefinitely.

 

34. National Organization for Rare Disorders (NORD)

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Botox Patient Assistance Program

Program Address

Botox Patient Assistance Program
C/O NORD
PO Box 8923
New Fairfield, CT 06812-8923

Medicines On Program

Botox

Phone Number

800.530.6680

Guidelines and Notes

The patient must be a US citizen or legal resident and have no insurance for Botox. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.

Initiating
Enrollment

Anyone may call to start the process, the application will be mailed to the patient, doctor or social worker. The completed application should be mailed back.

Health Provider's Role

The doctor completes a section, signs and attaches a prescription to the application.

Patient's Role

Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

Depends on amount awarded to patient,

Refills

New application only needed annually.

Limit

Indefinitely

 

35. Bradley Pharmaceuticals Indigent Patient Program

 

Pharmaceutical Company

Bradley Pharmaceuticals, Inc.

Program Name

Bradley Pharmaceuticals Indigent Patient Program

Program Address

383 Route 46 West
Fairfield NJ, 07004
Attn: Indigent Patient Program

Medicines On Program

Anamantle HC Cream 3%, Brontex III Tablets, Brontex Syrup, Carmol Cream 40 1oz, Carmol Cream 40 3oz, Carmol Cream 40 7oz, Carmol Gel 15ml, Carmol Lotion 8oz, Carmol Scalp Treatment Kit, Carmol Scalp Treatment Lotion 3 oz, Deconamine Capsules 60mg, Deconamine SR 120mg, GlutoFac-MX , GlutoFac-ZX, LidaMantle Cream 3oz, LidaMantle HC Cream 3oz, LidaMantle HC Lotion 177 ml, LidaMantle Lotion 177 ml, Pamine 2.5ml Tablet, Pamine 5 ml Tablet , Rosula Cleanser 355ml, Rosula Gel 1.5 oz , Tyzine Nasal 30ml, Tyzine Nasal Drops 15ml, Tyzine Nasal Solution 30ml, Tyzine Nasal spray 15ml

Phone Number

800-929-9300

Guidelines and Notes

The patient must have an annual income of less than $25,000 for a family of two and be a resident of the US.

Initiating
Enrollment

Anyone can call to start the process with the patient and doctor's basic information. The company will then send the partially completed application to the doctor's office to be finished. The completed application can be faxed or mailed back in.

Health Provider's Role

The phyisician must complete and sign a section of the application and include a prescription for up to 90 days. The physician should write the following on the prescription, "Prescription of Indigent."

Patient's Role

The patient provides Social Security Number, Annual Income and basic information. The patient does not need to sign the application

How Dispensed

The medications are sent to the phyisician's office.

Amount Dispensed

The medication is sent out in a 90 day supply.

Refills

For a refills, the doctor must send in a prescription. After one year a whole new application is needed.

Limit

Indefinitely.

 

36. Bridge Program for Genotropin

 

Pharmaceutical Company

Pfizer, Inc.

Program Name

Genotropin

Program Address

3168 Riverport Tech Center Drive
Maryland Heights, MO 63043

Medicines On Program

Genotropin

Phone Number

800-645-1280, option 3

Guidelines and Notes

Patient must be a US resident, have no insurance and met in-house financial guidelines. The patient must need the medication for FDA approved diagnosis.

Initiating
Enrollment

Anyone can call to get an application, The Statement of Medical Necessity, sent out. There are two applications: one for adults and one for children.

Health Provider's Role

The doctor must fill out the Statement of Medical Necessity, sign and attach a prescription. For children, a growth chart is also required.

Patient's Role

Once the Statement of Medical Necessity is sent in, the company wiill contact the patient. The patient must provide proof of income.

How Dispensed

Medication is sent to patient or doctor's office but someone must be there to sign for the medication.

Amount Dispensed

Medication is sent out one month at a time.

Refills

The patient must call for a refill. After a year the company will need updated insurance and financial information.

Limit

Indefinitely.

 

37. Bristol Meyers Squibb Patient Assistance Program for Abilify

 

Pharmaceutical Company

Bristol-Myers Squibb Company

Program Name

Bristol Meyers Squibb Patient Assistance Program for Abilify

Program Address

PO Box 29020
Phoenix AZ 85038-9020

Medicines On Program

Abilify

Phone Number

800-736-0003, opt 1

Guidelines and Notes

Call between the hours of 9am and 6pm EST. Patient must be a US resident and be at or below 200% of the Federal Poverty Guidelines. The patient must also meet certain insurance guidelines that the company does not disclose.

Initiating
Enrollment

Anyone can call for an application and it be mailed or faxed out. The blank application can be copied. The completed application can be mailed or faxed back.

Health Provider's Role

Doctor fills out a section with basic information included DEA and state lincense number. The doctor must sign the application as well.

Patient's Role

Provide basic personal, insurance, income and expense information and sign form.

How Dispensed

The medication is sent to physician.

Amount Dispensed

A ninty day supply is sent out.

Refills

A form is mailed to the doctor's office, it needs to be sent back with doctor's signature to get refilled. After a year a new application is needed.

Limit

indefinitely

 

38. Bristol-Meyers Squibb Access Access Program

 

Pharmaceutical Company

Bristol-Myers Squibb Company

Program Name

Bristol-Meyers Squibb Access Access Program

Program Address

6900 College Blvd., Suite 1000
Overland Park, KS 66211-9840

Medicines On Program

BiCNU, Blenoxane, CeeNU, Cytoxan I.V., Cytoxan tablets 25 mg, Cytoxan tablets 50mg, Droxia, Etopophos, Hydrea, Ifex, Lysodren, Megace Oral Suspension, Mesnex, Mutamycin, Paraplatin, Platinol-AQ, Reyataz, Sustiva, Taxol, Teslac, Vepesid Capsules, Vepesid I.V., Videx, Videx EC, Vumon, Zerit, Zerit Oral Solution

Phone Number

800-272-4878

Guidelines and Notes

Patients must have no insurance coverage for prescription needed. The patient must be treated out-patient and treated on an ongoing process. Patients must also meet financial guidelines that are not disclosed. Call between 8-5pm CST.

Initiating
Enrollment

The doctor's office should call for an application, the application will be faxed out. If application is downloaded from NeedyMeds the doctor's office must call before the application is sent in. A case number is needed or the application is invalid. The completed application can be mailed or faxed back.

Health Provider's Role

The doctor must fill out a section and sign the application. Once the application is filled out the doctor must call the company to get the patient's unique case number and instruction on sending the application in.

Patient's Role

The patient or patient advocate needs to fill out a section with financial and insurance information. The must also sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

For the oncology medications a 2 month supply is sent out. For the virology medications a three month supply. Hydrea and Cytoxan Tablets are sent out in a 6 month supply.

Refills

With the supply is a fax that the doctor must fill out and sent back to get refills. A new application is need every six months for all the medications except Cytoxan Tablets and Hydrea which need new applications once a year.

Limit

Indefinitely as long as drug needed.

 

 

39. Bristol-Myers Squibb Patient Assistance Foundation

 

Pharmaceutical Company

Bristol-Myers Squibb Company

Program Name

Bristol-Myers Squibb Patient Assistance Foundation

Program Address

PO Box 52112
Phoeniz, AZ 85072-2112

Medicines On Program

Avalide Tablet 150 mg/12.5, Avalide Tablet 300 mg/12.5 mg, Avapro Tablet 150 mg, Avapro Tablet 300 mg, Avapro Tablet 75 mg, BuSpar Dividose Tablet 15 mg, Cefzil Oral Suspension 125mg/5 ml, Cefzil Oral Suspension 250 mg/5ml, Cefzil Tablet 250 mg, Cefzil Tablet 500 mg, Coumadin Tablet 1 mg, Coumadin Tablet 10 mg, Coumadin Tablet 2 mg, Coumadin Tablet 2.5 mg, Coumadin Tablet 3 mg, Coumadin Tablet 4 mg, Coumadin Tablet 5 mg, Coumadin Tablet 6 mg, Coumadin Tablet 7.5 mg, Desyrel Dividose Tablet 150 mg, Desyrel Dividose Tablet 300 mg, Dovonex topical cream .005%, Dovonex topical ointment .005%, Dovonex topical solution .005%, Glucophage Tablet 1000 mg, Glucophage Tablet 500 mg, Glucophage Tablet 850 mg, Glucophage XR Tablet 500 mg, Glucophage XR Tablet 750 mg, Glucovance tablet 1.25 mg/250 mg, Glucovance tablet 2.5 mg/500 mg, Glucovance tablet 5 mg/500 mg, K-Lyte CL tablet eff 25 meq, K-Lyte DS Tablet eff 50 meq, K-Lyte Tablet eff 25 meq, Kenalog .05% cream 20g topical cream .1%, Kenalog .1% cream 15g topical cream .1%, Kenalog .1% cream 60g topical cream.1%, Kenalog .1% cream 80g topical cream .1%, Kenalog .1% lotion 60 ml topical lotion .1%, Kenalog .1% ointment 15g topical ointment .1%, Kenalog .1% ointment 60 g topical ointment .1%, Kenalog 10 5 ml vial 10 mg/ml, Kenalog 40, 1 ml vial 40 mg/ml, Kenalog aerosol topical spray .1%, Kenalog in oralpaste 0.1%, Klotrix Tablet sa 10 meq, Lac-Hydrin Topical Cream 12%, Lodosyn Tablet 25 mg, Metaglip 2.5 mg/250mg, Metaglip 2.5 mg/500mg, Metaglip 5.0mg/500mg, Monopril HCT Tablet 10/12.5 mg, Monopril HCT Tablet 20/12.5 mg, Monopril Tablet 10 mg, Monopril Tablet 20 mg, Monopril Tablet 40 mg, Naturetin Tablet 5 mg, Plavix Tablet 75 mg, Pravachol Tablet 10 mg, Pravachol Tablet 20 mg, Pravachol Tablet 40 mg, Pravachol Tablet 80 mg, Pravigard PAC tablet 325 mg/20 mg, Pravigard PAC tablet 325 mg/40 mg, Pravigard PAC tablet 325 mg/80 mg, Pravigard PAC tablet 81 mg/20 mg, Pravigard PAC tablet 81 mg/40 mg, Pravigard PAC tablet 81 mg/80 mg, Prolixin Elixir .5mg/ml, Prolixin Oral Concentrate 5 mg/ml, Prolixin Tablet 10 mg, Prolixin Tablet 5 mg, Pronestyl Capsule 250 mg, Pronestyl Tablet 375 mg, Pronestyl Tablet 500 mg, Pronestyl-SR Tablet 500, Sinemet Tablets 10 mg/100 mg, Sinemet Tablets 25mg/100 mg, Sinemet Tablets 25mg/250 mg, Tequin Tablets 200 mg, Tequin Tablets 400 mg, Tequin Tablets Teq-Paq 400 mg, Ultravate Topical Cream .05%- Jar 15 g, Ultravate Topical Ointment .05%- Jar 50 g, Ultravate Topical Ointment .05%- Tube 15 g, Vasodilan Tablet 10 mg, Vasodilan Tablet 20 mg

Phone Number

800-736-0003, ext 2

Guidelines and Notes

Call Monday through Friday 9-6PM Eastern Time. There is a separate program for the oncology. Patient must be a US Citizen or legal resident alien. Physician and patient are notified regarding acceptance or denial of application. The address on the application must be the same as the address listed with the DEA number of the prescriber.

Initiating
Enrollment

Doctor or patient can call for form which will be automatically faxed 24 hours a day. A The completed application can be mailed or faxed back.

Health Provider's Role

Doctor completes physician section which includes DEA# and signs form including the RX section which takes the place of a prescription. There is a list of drugs and the "NDC Number" for the drug must be on the form as well as the name of the drug.

Patient's Role

Provide basic information including gross monthly income and size of household, and whether or not patient has public or private prescription insurance and sign form.

How Dispensed

The medication is sent to the prescriber.

Amount Dispensed

The first shipment is sent in a 6 month supply, then the next two shipments are sent in 90 day supplies.

Refills

Patient or doctor need to call to get refills. A new application can be used to change the dosage for an existing patient; the physician would indicate that on the prescription section of the form. Once a year a whole new application is needed.

Limit

Indefinitely

 

40. Buphenyl And Urea Cycle Treatment Assistance Program

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Buphenyl And Urea Cycle Treatment Assistance Program

Program Address

C/O NORD
PO Box 1968
Danbury, CT 06813-1968

Medicines On Program

Buphenyl, Urea Cycle Therapy

Phone Number

800.711.0811

Guidelines and Notes

Each case is reviewed individually, but is based on patient's income and lack of perscription coverage. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.

Initiating
Enrollment

Anyone can call to start the process, and after some phone screening an applicatoin is sent to the patient, case worker or phyisician. The completed application must be mailed back to the company.

Health Provider's Role

The doctor must fill out a section and sign.

Patient's Role

The patient must fill out a section about financial and insurance information. The patient may be required to provide proof of income. The patient also needs to sign the application.

How Dispensed

The medication is sent via a mail order pharmacy to the patient's house.

Amount Dispensed

Amount sent depends on the amount awarded to the patient.

Refills

New applications are needed annually.

Limit

Indefinitely

 

41. Busulfex Patient Assistance Program

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Busulfex Patient Assistance Program

Program Address

Busulfex Patient Assistance Program
C/O NORD
PO Box 1968
New Fairfield, CT 06812-8923

Medicines On Program

Busulfex

Phone Number

800.999.6673

Guidelines and Notes

The patient must be a US citizen or legal resident and have no insurance for the medication. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assistance up from 25%-100% for one year. A negative decision can be appealed.

Initiating
Enrollment

Anyone may call to start the process, the application will be mailed to the patient, doctor or social worker. The completed application should be mailed back.

Health Provider's Role

The doctor completes a section, signs and attaches a prescription to the application.

Patient's Role

Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the form.

How Dispensed

Medication is sent to the doctor's office.

Amount Dispensed

Depends on amount awarded to patient.

Refills

New application only needed annually.

Limit

Indefinitely

 

42. Cancer Support Network for Iressa

 

Pharmaceutical Company

Astra Zeneca Pharmaceuticals

Program Name

Cancer Support Network for Iressa

Program Address


ot Applicable

Medicines On Program

Iressa 250 mg

Phone Number

866-992-9276, opt #1

Guidelines and Notes

To get assistance for Iressa, patients must first call the Reimbursment Network. This specialist will try to find funding sources for the patient. If there is no funding for the patient. Then an application will be sent out with a required code on it. The rest of the application process is then handled through the Astra Zeneca Foundation Patient Assistance Program.

Initiating
Enrollment

The doctor or patient can call to start the prescreening done over the phone. The caller needs to have insurance, medical and household income for the patient.

Health Provider's Role

Doctor completes and signs a section of the application. A prescription must be attached or fill out the prescription information on the appilcation.

Patient's Role

The patient must fill out the patient section and sign it. They must also attach proof of income and either a denial letter from Medicaid or a copy of the Medicaid card.

How Dispensed

The medication can be sent to either the patient or the doctor.

Amount Dispensed

A three month supply.

Refills

20 to 30 days before the medication runs out, the patient must call the number on the medication bottle for a refill. Totally new applications needed once a year. A re-application is sent 45 days prior to one year expiration date.

Limit

Indefinitely.

 

43. Care First and Compehensive Care Program

 

Pharmaceutical Company

Axcan-Scandipharm, Inc

Program Name

Care First and Compehensive Care Program

Program Address

PO Box 52065
Phoenix AZ, 85072-9152

Medicines On Program

Ultrase EC, Ultrase MT12

Phone Number

1-866-292-2679, opt 1

Guidelines and Notes

There are two components to this program. The first is the Care First Program. This is available to children under two years of age with cystic fibrosis. The Comprehensive Care Program provides ScandiShake or ScandiCal, ADEKs viamin drops or tablets and a flutter device (if prescribed) to patients over 2 years old who are taking Ultrace. Once a patient is enrolled in the Care First Program they will recieve more details about the Compehensive Care Program when the patient turns two. The patient must send in the receipts from the Ultrace to get the supplements which are mailed to the patients home. In order to get more, just send in more receipts. The amount sent matches the amount of Ultrace taken.

Initiating
Enrollment

The enrollment is done over the phone. Anyone can call as long as have the proper information which included doctor's name address, phone number, patient home number, parent name, home address.

Health Provider's Role

NA.

Patient's Role

Patient only needs to be in need.

How Dispensed

For the Care First, the patient is given an ID number and group number which is taken to the pharmacy and the patient is given the medication.

Amount Dispensed

The patient gets either a 30 or 90 supply at one time from the pharmacy. Once the patient is enrolled they just go back to the pharmacy for refills.

Refills

Once the patient is enrolled they just go back to the pharmacy for refills. Until the patient turns two, s/he is in the program.

Limit

Indefinitely.

 

44. Carnitor Drug Assistance Program

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Carnitor Drug Assistance Program

Program Address

Carnitor Drug Assistance Program
C/O NORD
PO Box 1968
New Fairfield, CT 06812-8923

Medicines On Program

Carnitor Injection 1gm/5ml, Carnitor Injection 200 mg/ml, Carnitor Oral Solution , Carnitor Tablets 330mg

Phone Number

800.999.6673

Guidelines and Notes

The patient must be a US citizen or legal resident and have no insurance for the medication. The patient must also demonstrate having a legal prescription for Carnitor. If patient is a minor then the families income information is also needed. Each application is reviewed individually to determine eligibility. Estimated time of response is 2 to 4 weeks. The patient is given assistance up from 25%-100% for one year. A negative decision can be appealed.

Initiating
Enrollment

Anyone may call to start the process, the application will be mailed to the patient, doctor or social worker. The completed application should be mailed back.

Health Provider's Role

The doctor completes a section, signs and attaches a prescription to the application.

Patient's Role

Patient needs to fill out a section with detailed financial and insurance information. The patient will also need to provide proof of income, and sign the form.

How Dispensed

Medication is sent directly to the patient through a mail order pharmacy.

Amount Dispensed

A 90 day supply is sent at one time

Refills

New application is needed annually.

Limit

Indefinitely

 

45. Celgene Therapy Patient Assistance Program

 

Pharmaceutical Company

Celgene Corporation

Program Name

Celgene Therapy Patient Assistance Program

Program Address

6900 College Blvd. Suite 1000
Overland Park, KS 66211

Medicines On Program

Thalomid

Phone Number

888-423-5436, #3

Guidelines and Notes

Patient must have no insurance that covers the drug or they have maxed out their drug insurance benefits. Patient must meet the companies finanical guidelines that are not disclosed. They make and fax determination with instructions in two buisness days and also call to confirm the physician's office.

Initiating
Enrollment

Physician's office must call to get an application faxed to the office. This application can be copied. Completed application can be faxed back.

Health Provider's Role

Health care provider needs to sign and date a section of the application. Prescription is not needed until patient is approved for program. Once approved the company will contact the doctor for the perscription.

Patient's Role

Patient must fill out a section of the application and sign and date. Photocopies of both the front and back of the patient's health insurance card(s) must also be included.

How Dispensed

The company sends the medication to the doctor's office.

Amount Dispensed

The medication is sent in a one 28 day cycle.

Refills

To get refills the doctor must fax a new prescription to 1-888-432-9325 dated no more than seven days before the next treatment date. Once the patient is accepted to the program, theyare in the program as long as they are continuously taking the medication. After three months of not using the medication a new application is needed.

Limit

Indefinitely

 

 

 

 

46. Celltech Patient Assistance Program

 

Pharmaceutical Company

Celltech Pharmaceuticals, Inc.

Program Name

Celltech Patient Assistance Program

Program Address

PO Box 430
Heckettstown, NJ 07840

Medicines On Program

Dipentum, Gastrocrom Oral Concentrate, Semprex-D, Zaroxolyn 10 mg, Zaroxolyn 2.5 mg, Zaroxolyn 5 mg

Phone Number

866-523-3994

Guidelines and Notes

Patients must not have any third party coverage and must meet stringent income guidelines. Patient household income must be no more than 150% of the federal poverty level. Make sure application is complete and that all required documentation is included.

Initiating
Enrollment

Anyone can call to get an application. Doctor's offices can also fill out the application at rxhope.com Completed application can be faxed back.

Health Provider's Role

The doctor needs to complete a section, sign the application and attach a prescription.

Patient's Role

The patient must fill out a section about income and insurance, sign and attach proof of income to application.

How Dispensed

Medications are sent to provider prescribing them, usually within four weeks of receipt of application.

Amount Dispensed

The medication is sent in a three month supply.

Refills

Use entirely new application, just like first time, sent in with proof of income and prescription.

Limit

Unspecified

 

47. Cenestin Patient Assistance Program

 

Pharmaceutical Company

Dura-Med Pharmaceuticals, Inc

Program Name

Cenestin Patient Assistance Program

Program Address

1878 Arena Drive
Hamilton, NJ 08610

Medicines On Program

mg Tablets, Cenestin 0.3 mg Tablets, Cenestin 0.45 mg Tablets, Cenestin 0.625, Cenestin 0.9 mg Tablets, Cenestin 1.25 mg Tablets

Phone Number

800-425-3122

Guidelines and Notes

The patient must be a US resident who does not have insurance or any prescription coverage. The patient's annual income must fall below $15,000 if single and $25,000 if married.

Initiating
Enrollment

If someone calls for an application, the company take some information and faxes a patient specific application to the doctor's office. Or a blank application can be filled out and returned. The completed application can be faxed or mailed back to the company

Health Provider's Role

The doctor must fill out a section and sign the application.

Patient's Role

The patient must fill out a section about insurance and income, and sign the application in two places.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The medication is shipped in a 100 day supply

Refills

To get refills the doctor or patient must call for a Requalification Form that must be filled out and sent back. After a year a whole new application is needed.

Limit

Indefinitely.

 

48. Cetylite Industries, Inc

 

Pharmaceutical Company

Cetylite Industries, Inc

Program Name

Cetylite Industries, Inc.

Program Address

PO Box 90006
Pennsauken, NJ 08110

Medicines On Program

Cetacaine

Phone Number

800-257-7740

Guidelines and Notes

They have an informal program; decisions are made on a case-by-case basis. They make Cetacaine spray, liquid and ointment which is used as a topical anesthetic to control pain.

Initiating
Enrollment

Put request in writing on letterhead. and fax to them; if there's a problem they will get back to you. They will help if they can.

Health Provider's Role

Contact company.

Patient's Role

Minimal information required, would be on-file already.

How Dispensed

not specified

Amount Dispensed

not specified

Refills

Not Applicable

Limit

Not Applicable

 

49. Charitable Access Program

 

Pharmaceutical Company

Genzyme Corporation

Program Name

Charitable Access Program

Program Address

500 Kendall St
Cambridge, MA 02142

Medicines On Program

Aldurazyme, Ceredase, Cerezyme, Fabrayzyme

Phone Number

800-745-4447, ext 16634

Guidelines and Notes

The patient must also have one the three FDA approved diseases: Gaucher, Fabry, or MPS I Disease. The patient must have no insurance that will cover the medication, or have exhausted the insurance.

Initiating
Enrollment

The doctor can call the company to get an application. The application is mailed out to the patient. The completed application needs to mailed back.

Health Provider's Role

The doctor needs to complete a letter of intent to treat, and a statement of medical necessity.

Patient's Role

The patient needs to fill out a section that asks for detailed financial and insurance information. The patient must also sign the application and need to submit the last three years of tax returns and last three months of bank statements.

How Dispensed

The medication is sent to the doctor's office or infusion site.

Amount Dispensed

The amount sent depends on the patient's medical needs. Aldurazyme is sent in a one week dose, the others are sent for an every other week doseage.

Refills

Refills are case by case, speak to the company once enrolled in the program.

Limit

N/a

50. Clozaril Patient Support Program

Pharmaceutical Company

Novartis Pharmaceuticals

Program Name

Clozaril Patient Support Program

Program Address


NA

Medicines On Program

Clozaril

Phone Number

800-257-3273, opt 1

Application

 

Guidelines and Notes

Before a patient can be enrolled both the patient and the doctor must be enrolled in the National Clozaril Registry (1-800-448-5938.) This is a one time, 12 week paperless program for Clozaril.

Initiating
Enrollment

Patient advocate or doctor must call the company to give basic patient and doctor information. The company give the patient an ID number. And a card is sent to the doctor's office. (84 days/12 week of therapy)

Health Provider's Role

Just call in to start the process and enroll in National Clozaril Registry.

Patient's Role

Enroll in National Clozaril Registry.

How Dispensed

The ID card is taken to a pharmacy to get the medication.

Amount Dispensed

Medication is given out in no more than a 14 day supply at one time.

Refills

The card is good for 12 weeks, the patient must just take the card back to get refills.

Limit

One time.

 

51. ConnecticsCare

 

Pharmaceutical Company

Connectics Corporation

Program Name

ConnecticsCare

Program Address


See Application for Mailing Address.

Medicines On Program

Luxiq Foam, Olux Foam , Soriatane

Phone Number

888-500-3376

Fax Number

N/A

Application

Contact program for application

Guidelines and Notes

The patient must be a US resident with no perscription coverage through a public or private program. The patient's income must be at or below 200% of the current Federal Poverty Level. The doctor can also request rebate certificates from her/his drug representative. These certificates can be given out with a prescription for Luxiq or Olux. The certificate is good for half of what the patient pays up to $25.00. The company also has an insurance verification program, to get reach that department call 1-800-572-3225. They refuse to give us any updated information, this information is current as of November 2003.

Initiating
Enrollment

The doctor's office must call to get a patient specific application mailed to the doctor's office. The completed application must be mailed back.

Health Provider's Role

The doctor must fill out a section and sign it.

Patient's Role

The patient must also sign the application.

How Dispensed

The medication sent to the doctor's office.

Amount Dispensed

A three month supply is out.

Refills

A new application is needed for each refill.

Limit

Indeinitely

 

52. Connections for Growth

 

Pharmaceutical Company

Serono Laboratories, Inc.

Program Name

Connections for Growth

Program Address

1 Technology Place
Rockland MA 02370

Medicines On Program

Saizen

Phone Number

800-582-7989

Guidelines and Notes

This is a last resort patient assistance program. The company first works with the patient's insurance to get the medication covered and/or appeal denials. The patient's family meet financial critera that are not disclosed.

Initiating
Enrollment

The doctor must start the process, by referring the patient to the company. The completed application can be faxed or mailed back into the company.

Health Provider's Role

The doctor must approve of medication being sent.

Patient's Role

The guardian must fill out the application, sign and attach proof of income and medical documents.

How Dispensed

The medication is sent to a doctor's office.

Amount Dispensed

The medication is sent in a 3 month supply, unless the doctor notes otherwise.

Refills

The patient must call the company to get a refill at least 10 days before supply runs out. The company contacts the doctor for update and to get a new prescription. Every year a new application with documentation.

Limit

Indefinitely

 

53. Copaxone Patient Assistance Program

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Copaxone Patient Assistance Program

Program Address

C/O NORD
PO Box 1968
Danbury, CT 06813-1968

Medicines On Program

Copaxone

Phone Number

800.887.8100

Guidelines and Notes

Each case is reviewed individually, but is based on patient's income and lack of perscription coverage. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.

Initiating
Enrollment

Anyone can call to start the process, and after some phone screening an applicatoin is sent to the patient, case worker or phyisician. The completed application must be mailed back to the company.

Health Provider's Role

The doctor must fill out a section and sign.

Patient's Role

The patient must fill out a section about financial and insurance information. The patient may be required to provide proof of income. The patient also needs to sign the application.

How Dispensed

The medication is sent via a mail order pharmacy to the patient's house.

Amount Dispensed

Amount sent depends on the amount awarded to the patient.

Refills

New applications are needed annually.

Limit

Indefinitely

 

54. Cystadane Patient Assistance Program

 

Pharmaceutical Company

National Organization for Rare Disorders (NORD)

Program Name

Cystadane Patient Assistance Program

Program Address

C/O NORD
PO Box 1968
Danbury, CT 06813-1968

Medicines On Program

Cystadane

Phone Number

800.999.6673

Guidelines and Notes

Each case is reviewed individually, but is based on patient's income and lack of perscription coverage. The patient is given assitance up from 25%-100% for one year. A negative decision can be appealed.

Initiating
Enrollment

Anyone can call to start the process, and after some phone screening an application is sent to the patient, case worker or phyisician. The completed application must be mailed back to the company.

Health Provider's Role

The doctor must fill out a section and sign the application.

Patient's Role

The patient must fill out a section about financial and insurance information. The patient may be required to provide proof of income. The patient also needs to sign the application.

How Dispensed

The medication is sent via a mail order pharmacy to the patient's house.

Amount Dispensed

Amount sent depends on the amount awarded to the patient.

Refills

New applications are needed annually.

Limit

Indefinitely

 

55. Dermik Laboratories Patient Assistance Program

 

Pharmaceutical Company

Dermik Laboratories, Inc

Program Name

Dermik Laboratories Patient Assistance Program

Program Address

PO Box 651
Somerville NJ, 08876

Medicines On Program

BenzaClin Topical Gel 25 gr, Benzagel 42.5 gram Tube, Benzagel Wash 60 gram tube, Benzamycin Topical Gel 46.6 gram jar, Carac Cream 30 gram tube, Hytone Cream 56.8 gram tube, Hytone Lotion 59 mL Bottle, Klaron Lotion 4 oz, Noritate Cream 30 gram Tube, Penlac 6.6 mL, Psorcon Cream 60 gram Tube, Psorcon E Cream 60 gram Tube, Psorcon E Ointment 60 gram Tube, Psorcon Ointment 60 gram Tube, Sulfacet-R 25 gram Bottle, Vytone Cream 28.4 gram Tube

Phone Number

866-268-7326

Guidelines and Notes

A patient must be a US resident and cannot have or qualify for any goverment perscription coverage or any state or local programs. A patient cannot have or quailfy for any private prescription coverage such as HMO or PPO. The total annual household income must be at or below 200% of the Federal Poverty Level.

Initiating
Enrollment

Anyone can start the process, and the application will be faxed out. It can be copied. The application must be mailed in.

Health Provider's Role

The doctor must fill out a section that includes DEA#, a prescription for a max of three months, and sign the form.

Patient's Role

The patient must fill out a section and sign it. They must also provided a copy of a tax return or proof of income.

How Dispensed

The medication is sent to the doctor's office. Allow 4 weeks for processing.

Amount Dispensed

A three month supply is sent, each drug has different quantities but it very clearly outlined on the application.

Refills

Every three months a new application and prescription must be sent in. But the proof of income is only required once a year.

Limit

Indefinitely

 

 

56. Dexferrum Reimbursement Hotline and Patient Assistance Program

 

Pharmaceutical Company

American Regent, Inc.

Program Name

Dexferrum Reimbursement Hotline and Patient Assistance Program

Program Address

C/O InteleCenter
PO Box 4280
Gaithersburg, MD 20885-4133

Medicines On Program

Dexferrum

Phone Number

800-282-7712, Opt 2

Guidelines and Notes

The patient must be a US resident, and be taking the medication for an FDA approved diagnosis. The company also has income and insurance guidelines that they do not disclose. This is a product replacement program

Initiating
Enrollment

The doctor or treatment center must start to get an application faxed out. The completed application can be faxed back.

Health Provider's Role

The doctor needs to fill out a section and sign it.

Patient's Role

The patient also needs to filil out a section and sign it.

How Dispensed

The medication is sent to the treatment center.

Amount Dispensed

The amount requested is the amount sent.

Refills

The patient is enrolled for a year, after which a new application is needed. A product replacement form is needed for refills and are sent out once a patient is accepted into the program.

Limit

Indefinitely

 

 

 

 

 

 

 

57. Digestive Care, Inc Assistance Program

 

Pharmaceutical Company

Digestive Care, Incorporated

Program Name

Digestive Care, Inc Assistance Program

Program Address

1120 Win Drive
Bethlehem, PA 18017

Medicines On Program

Pancrecarb MS 16 DR

Phone Number

Not Applicable

Guidelines and Notes

The patient must not be covered by medical insurance, Medicaid or other third party payers. Eligibility is determined on a case-by-case basis.

Initiating
Enrollment

The physician submits a written request outlining the situation and indicate what assistance is needed. The letter must be mailed in.

Health Provider's Role

See Above.

Patient's Role

The patient needs to tell her/his doctor that s/he cannot afford the medication, and have no insurance.

How Dispensed

The medication is sent to the physician's office. The medication will be shipped within 5 business days.

Amount Dispensed

The normal amount sent out is a 3 month supply.

Refills

If refills are needed another originial request must be submitted, after 3 months.

Limit

Unspecified

 

 

 

 

 

 

 

58. Doxil Reimbursement Solutions

 

Pharmaceutical Company

Ortho Biotech Products, L.P.

Program Name

Doxil Reimbursement Solutions

Program Address

PO Box 1016
San Bruno CA 94066

Medicines On Program

Doxil

Phone Number

800-609-1083, opt 1

Guidelines and Notes

The company provides insurance verification. But the program is for patients who meet their financial guidelines, which they don't release and must be have no insurance or have reached their insurance limits.

Initiating
Enrollment

Anyone can call to get an application, and it will be faxed out. The blank application can be copied. The completed application can be faxed.

Health Provider's Role

Provide medical information and sign the application.

Patient's Role

Patient must provide proof of income and sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The medication is sent out one month at a time.

Refills

After three weeks the company call the doctor's office to see if a refill is needed, if so another supply is sent out. After six months another application is fiilled out and sent in, but unless changes have occured, no need to send in proof of income. Proof of income is only needed once a year.

Limit

indefinitely

 

 

 

 

59. ECR Pharmaceuticals Patient Assistance Program

 

Pharmaceutical Company

ECR Pharmaceuticals

Program Name

ECR Pharmaceuticals Patient Assistance Program

Program Address

PO Box 71600
Richmond, VA 23255

Medicines On Program

Anaplex DM Cough Syrup, Anaplex HD Cough Syrup, Bupap, Dexpak , Lodrane 12 D, Lodrane 12 hour , Lodrane liquid, Nasatab LA tablets, Panalgesic Gold cream, Panalgesic Gold liniment, Pneumotussin 2.5 cough syrup, Pneumotussin tablets

Phone Number

800-527-1955

Guidelines and Notes

This is an informal program with no application

Initiating
Enrollment

Doctor writes letter on letterhead stating patient's need and lack of prescription coverage, attaches prescription or just explains situation to representative and gives him or her prescription for the patient.

Health Provider's Role

See above.

Patient's Role

No patient information needed.

How Dispensed

Sends medicine to doctor's office.

Amount Dispensed

One bottle of 100.

Refills

To get refills the doctor must write a new letter.

Limit

Unspecified

 

 

60. Eldepryl Patient Rewards Program

 

Pharmaceutical Company

Somerset Pharmaceuticals, Inc.

Program Name

Eldepryl Patient Rewards Program

Program Address

2202 North Westshore Blvd., Ste. 450
Tampa, FL 33607

Medicines On Program

Eldepryl

Phone Number

800-892-8889

Guidelines and Notes

This is a rewards program --after purchase of two months supply of Eldepryl send in receipt and they will send a free month-supply. Patients can use this program indefinitely. They will gladly send brochures for patients.

Initiating
Enrollment

Patient can call in for form that needs to be filled out. For every two receipts, patient can get a third bottle free. The completed form must be mailed in with a prescription.

Health Provider's Role

N/A

Patient's Role

Ask pharmacist for "duplicate prescription receipt" indicating purchase of Eldepryl. Obtain additional one month prescription from prescriber. Fill out self-mailer, attach prescription and send in.

How Dispensed

The medication is sent to the patient's house.

Amount Dispensed

A one month supply is sent in.

Refills

Repeat the process after buying two more months supply.

Limit

Indefinitely

 

 

 

 

 

61. Eloxatin Reimbursement Hotline

 

Pharmaceutical Company

Sanofi-Synthelabo Pharmaceuticals, Inc.

Program Name

Eloxatin Reimbursement Hotline

Program Address

C/O Sanofi
90 Park Ave.
New York, NY 10016

Medicines On Program

Eloxatin

Phone Number

877.435.6928 opt 5

Fax Number

877.366.0584

Application

Contact program for application

Guidelines and Notes

The patient must be enrolled before receiving treatment. (There is no retroactive reimbursement.) The patient must meet financial guidelines which are not disclosed and must be a US resident that cannot qualify for any public assistance programs.

Initiating
Enrollment

The company prefers that the doctor calls to get the application. The application is faxed to the doctor. The completed application can be faxed back to the company.

Health Provider's Role

The doctor must fill out a section, sign it and attach a prescription.

Patient's Role

The patient must fill out a section about income and sign.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The amount sent is based on the patient's medical needs per treatment.

Refills

A new prescription is faxed to the company by the doctor for every months. After 3 months a Recertification Form is faxed to the doctor to be filled out and faxed back. After 6 months a new application is needed.

Limit

Indefinitely

62. Encourage Foundation

 

Pharmaceutical Company

Wyeth & Amgen

Program Name

.

Program Address

C/O Intele Center Foundation
PO Box 4133
Gaithersburg, MD 20885-4133

Medicines On Program

Enbrel

Phone Number

800-376-2580

Guidelines and Notes

If the patient states that they cannot afford the medication, they should be encouraged to call the program or just apply. The program will provide case management -- trying to find altnerate resources -- for patients who don't meet their guidelines.

Initiating
Enrollment

Staff will screen patient over the phone and if they seem to qualify, application will be sent to the patient, which is patient specific. Once application is complete mail or fax it back, they will review the information. If the patient qualifies then a prescription form is sent to the doctor.

Health Provider's Role

The doctor fills out the prescription form and mails that to the company.

Patient's Role

The patient must fill out the initial application, sign and attach proof or income (must be 1040 if filed taxes, if not a noterizied statement of income.)

How Dispensed

Medications are to the patient's house unless the patient requests different.

Amount Dispensed

Patient is sent one month supply for 4 months, then 2 month supply for 4 months, and after that 3 month supply sent at a time.

Refills

The refills are sent out automatically, but the company calls to set up a delivery time. The patient is first enrolled for 4 months, then the doctor needs to sign a new prescription form. After 8 months the doctor needs to sign another prescription form. The patient only needs to fill out a new application once a year.

Limit

Indefinitely.

 

63. Endo Pharmaceuticals, Inc.

 

Pharmaceutical Company

Endo Pharmaceuticals, Inc.

Program Name

Endo Pharmaceuticals, Inc.

Program Address

PO Box 430
Hackettstown, NJ 07840

Medicines On Program

Lidoderm, Moban, Symmetrel

Phone Number

800-319-4032

Guidelines and Notes

Patient's eligibility is based on income and lack of prescription benefits.

Initiating
Enrollment

The doctor's office must fill out an application on www.rxhope.com (Need a DEA number to be given access to the application.) Or the doctor's office can call for an application to be faxed out.

Health Provider's Role

The doctor must fill out the application which included medical information, insurance information and income information of the patient.

Patient's Role

Provide the needed information to the doctor.

How Dispensed

The medication is sent to the doctor's office

Amount Dispensed

Lidoberm is sent in a two month supply, Moban and Symmetrel are sent in a three month supply.

Refills

For each refill a new application is needed.

Limit

Unclear.

 

 

 

64. ESP Pharma Patient Assistance Program

 

Pharmaceutical Company

ESP Pharma

Program Name

ESP Pharma Patient Assistance Program

Program Address

PO Box 430
Hackettstown, NJ 07840

Medicines On Program

Declomycin 150mg, Declomycin 300mg, Ismo 20mg, Sectral 200mg, Sectral 400mg, Tenex 1mg, Tenex 2mg

Phone Number

800-319-4031

Guidelines and Notes

Patient's income must be at or below 200% of the Federal Poverty Level and have no prescription insurance.

Initiating
Enrollment

Call the above number and a copy of the application will be faxed out. The completed application can be faxed back to the company.

Health Provider's Role

The doctor must fill out and sign one section of the application.

Patient's Role

The patient must fill out and sign two sections of the application.

How Dispensed

The medication is sent to the physican's office.

Amount Dispensed

Two bottles of medication are sent out.

Refills

To get a refill, send in a new application.

Limit

Indefinitely.

 

65. Ethyol Protect Program

 

Pharmaceutical Company

Medimmune, Inc.

Program Name

Ethyol Protect Program

Program Address

PO Box 222197
Charlotte NC 28222-2197

Medicines On Program

Ethyol, Neutrexin 200mg/vil, Neutrexin 25mg/vil

Phone Number

800-887-2467

Guidelines and Notes

This program mostly deals with Ethyol, but also has an application for NeuTrexin. There are two programs with the same application. One is The Insurance Patient Program which is a safety net for physicians if the patient's insurance denies the claim. It also acts a benefits verification program. If the patient is denied coverage and the decision is appealed and still holds up, the company will send replacement medication to the phyisican's office. The Second program is for uninsured patients and provides medication to patients who met their requirements.

Initiating
Enrollment

Anyone can call for an application, and it will be faxed out. Blank applications can be copied. The application can be faxed back.

Health Provider's Role

The physician must provide basic information and sign a Physician or Provider Site Agreement. (Once this form is filled out for the site it doesn't have to be filled out for other patients.)

Patient's Role

Patient must provide information about insurance and/or financial information including total household income. Patient must also sign the application and the Patient Consent Form.

How Dispensed

Medication is sent to the phyisician's office.

Amount Dispensed

For Ethyol- up to 15 vials. For NeuTrexin- one cycle.

Refills

Sent with the medication is a refill form that the doctor must fill out and attach a prescription to for refills. After a year a whole new application is needed.

Limit

Indefinitely

 

66. Ferndale Laboratories, Inc.

 

Pharmaceutical Company

Ferndale Laboratories, Inc.

Program Name

Ferndale Laboratories, Inc.

Program Address

Customer Services
780 West Eight Mile Rd.
Ferndale, MI 48220

Medicines On Program

Analpram, LMX 4, LMX5, Locoid, Pramosone

Phone Number

800-621-6003, ext 442

Guidelines and Notes

The patient must be at or below the Federal Poverty Guidelines and US citizen with no prescription coverage.

Initiating
Enrollment

Anyone can call to start the process. The person will need basic patient and doctor information. The company will call the doctor's office to confirm the information and get a prescription.

Health Provider's Role

The doctor will have to provide a prescription.

Patient's Role

The patient will have to provide proof of income.

How Dispensed

All meds are sent to the doctor's office except for LMX which can be sent to the patient's home.

Amount Dispensed

It varies according to the prescription.

Refills

Doctor or patient calls for a refill. After 6 months the process must start over.

Limit

Indefinitely

 

 

 

 

 

 

67. Financial Assistance Program for Abelcet

 

Pharmaceutical Company

Enzon

Program Name

Financial Assistance Program for Abelcet

Program Address

750 The City Drive, Suite 210
Orange, CA 92868

Medicines On Program

Abelcet

Application

Contact program for application

Guidelines and Notes

Patient must have minimal resources and no insurance coverage for Abelcet, and be unable to afford the drug. Company encourages physicians to administer the drug and then file with them for reimbursement rather than wait for approval, given the critical indications for use of the drug. Eligibility is determined based on medical and financial factors. Patient must be getting Abelcet from hospital, physician or home health care company for a medically appropriate application.

Initiating
Enrollment

Anyone can call for an information packet and it will be mailed to doctor's office. The blank application cannot be copied. The completed application can be faxed back but the originial must be mailed in.

Health Provider's Role

Physicians complete, sign, then mail or fax the form. If a hospital is treating the patient then the hospital submits a consent form. Proof of patient diagnosis must be attached to application.

Patient's Role

The patient must fill out a section, including information about gross income.

How Dispensed

The drug is sent directly to the dispensing pharmacy approximately 48 hours later

Amount Dispensed

For reimbursment: As much as was used. For patient assistance program: a 30 day supply.

Refills

The provider must call the company to reapply and provide documents that more medication is needed.

Limit

Indefinitely

 

68. First Horizon Patient Assistance Program

 

Pharmaceutical Company

First Horizon Pharmaceutcical Corp.

Program Name

First Horizon Patient Assistance Program

Program Address

PO Box 66552
St Louis MO, 63166-6552

Medicines On Program

Cognex, Nitrolingual Pumpspray, Ponstel, Robinul, Robinul Forte, Sular

Phone Number

800-869-4514

Guidelines and Notes

Patient must be a US resident and have an income below Federal Poverty Guidelines or demonstrates that buying the medication will cause financial hardship.

Initiating
Enrollment

The patient or the provider can call for an application. If the patient calls it will be mailed to the patient's house. If the provider calls the application will be faxed to the office. The blank application be copied. Completed application must be mailed.

Health Provider's Role

Doctor completes and signs a section and included a prescription. The prescription can be made out for up to 3 refills, at 90 days a fill, except for Nitrolingual.

Patient's Role

Detailed financial and insurance information needed, as well as a signature. Proof of income is also required, 4506 Form is best.

How Dispensed

Medications sent to physician's office within 2-3 weeks of approval.

Amount Dispensed

The medication is sent out in a 90 day supply, except for Nitrolingual which is one bottle a year.

Refills

To get a refill the patient calls the company and requests a refill. (This only works if the doctor put refillls on the prescription.) A new application must be completed annually.

Limit

Indefinitely

 

69. First Resource Program

 

Pharmaceutical Company

Pfizer, Inc.

Program Name

First Resource Program

Program Address

6900 College Blvd, Ste 1000
Overland Park, KS 66211

Medicines On Program

Aromasin, Camptosar, Ellence, Emcyt, Idamycin, Trelstar , Zinecard

Phone Number

877-744-5675

Guidelines and Notes

The patient must be a US resident in the care of a US physician and requesting the medication for cancer. The patient must also have no insurance and meet financial guidelines that are not disclosed.

Initiating
Enrollment

For Aromasin and Emcyt the patient can start the process. The entire application process is done over the phone. For the other meidcations the doctor or doctor's office should call the start the process, then a patient specific application is sent out to the doctor's office. The completed application can be faxed in, but also must be mailed in.

Health Provider's Role

The provider must fill out a section and sign the application.

Patient's Role

The patient must fill out section, sign the application, and provide proof of income.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

A 30 day supply is sent out.

Refills

There a form that the doctor needs to fax in each month to get a refill. Once a year a new application with documentation is needed.

Limit

Indefinitely

 

70. Forest Pharmaceuticals Patient Assistance Program

 

Pharmaceutical Company

Forest Pharmaceuticals, Inc

Program Name

Forest Pharmaceuticals Patient Assistance Program

Program Address

13600 Shoreline Drive
St. Louis MO 63045

Medicines On Program

Aerobid Inhaler, 7 gm canister, Aerobid-M Inhaler, 7 gm canister, Aerochamber, Aerochamber with Mask, Armour Thyroid Tablets 1 gr, Armour Thyroid Tablets 1.5 gr, Armour Thyroid Tablets 1/2 gr, Armour Thyroid Tablets 1/4 gr, Armour Thyroid Tablets 2 gr, Armour Thyroid Tablets 3 gr, Armour Thyroid Tablets 4 gr, Armour Thyroid Tablets 5 gr, Celexa tablets 10 mcg, Celexa tablets 20 mcg, Celexa tablets 40 mcg, Kay Ciel Powder Packets, Levothroid Tablets 100 mcg, Levothroid Tablets 112 mcg, Levothroid Tablets 125 mcg, Levothroid Tablets 137mcg, Levothroid Tablets 150 mcg, Levothroid Tablets 175 mcg, Levothroid Tablets 200 mcg, Levothroid Tablets 25 mcg, Levothroid Tablets 300mcg, Levothroid Tablets 50 mcg, Levothroid Tablets 75 mcg, Levothroid Tablets 88 mcg, Lexapro Tablets 10 mg, Lexapro Tablets 20 mg, Tessalon Perles 100 mg, Tessalon Perles 200 mg, Theochron Tablets 100 mg, Theochron Tablets 200 mg, Theochron Tablets 300 mg, Thyrolar Tablets 1, Thyrolar Tablets 1/2, Thyrolar Tablets 1/4, Thyrolar Tablets 2, Thyrolar Tablets 3, Tiazac Capsules 120 mg, Tiazac Capsules 180 mg, Tiazac Capsules 240 mg, Tiazac Capsules 300 mg, Tiazac Capsules 360 mg, Tiazac Capsules 420 mg

Phone Number

800-851-0758

Guidelines and Notes

The patient must not be able to afford the medication and qualify under guidelines that the company does not release. It is important that the address on the prescription matches the mailing address on the applicatoin. If this is not the case please attach letterhead or buisness card to verify the delivery address. The current application list Esgic, but it is no longer covered on the program.

Initiating
Enrollment

Anyone can call to get an application, it will be faxed out. The blank application can also be copied. The completed application must be mailed back to the company.

Health Provider's Role

The doctor must fill out a section of the application, sign and attach a prescription.

Patient's Role

The patient must fill out a section and sign. The patient may be requested to show proof of income.

How Dispensed

The medication is sent directly to the doctor's office.

Amount Dispensed

The medication is sent out in a three month supply.

Refills

Each time the patient needs medication; a new application and prescription must be mailed to the company.

Limit

Indefinitely

 

71. Forest Pharmaceuticals Patient Assistance Program

 

Pharmaceutical Company

Forest Pharmaceuticals:Namenda

Program Name

Forest Pharmaceuticals Patient Assistance Program

Program Address

13600 Shoreline Drive
St Louis, MO 63045

Medicines On Program

Namenda Tablet, 10 mg, Namenda Tablet, 5 mg, Namenda Titration Pak

Phone Number

800-851-0758

Guidelines and Notes

The patient must not be able to afford the medication and qualify under guidelines that the company does not release. It is important that the address on the prescription matches the mailing address on the applicatoin. If this is not the case please attach letterhead or buisness card to verify the delivery address.

Initiating
Enrollment

Anyone can call to get an application, it will be faxed out. The blank application can also be copied. The completed application must be mailed back to the company.

Health Provider's Role

The doctor must fill out a section of the application, sign and attach a prescription.

Patient's Role

The patient must fill out a section and sign. The patient may be requested to show proof of income.

How Dispensed

The medication is sent directly to the doctor's office.

Amount Dispensed

The medication is sent out in a three month supply.

Refills

Each time the patient needs medication; a new application and prescription must be mailed to the company.

Limit

Indefinitely

 

72. Fujisawa Patient Assistance Program

 

Pharmaceutical Company

Fujisawa Healthcare, Inc.

Program Name

Fujisawa Patient Assistance Program

Program Address

PO Box 221644
Chantilly, VA 20153-1644

Medicines On Program

Adenocard Injection , Adenoscan , AmBisome, Aristocort A Cream, Aristocort A Ointment , Aristocort A Tablet 4mg

Phone Number

800-477-6472

Guidelines and Notes

The patient must be a US resident and meet financial and insurance guidelines that are not disclosed.

Initiating
Enrollment

Healthcare provider or patient must call for a pre-screening and will need patient's income and insurance information and some kind of proof of income to fax them. The application is patient specific and is sent to the provider's office. The completed application must be mailed back.

Health Provider's Role

The provider must fill out a section and sign the application.

Patient's Role

The patient needs to provide proof of income but doesn't need to sign the application.

How Dispensed

The medication is sent via UPS or FedEx to the provider's office.

Amount Dispensed

Depends on availability of medication.

Refills

A new application is needed, if more medication is needed.

Limit

Indefinite.

 

73. Fuzeon Reimbursment Assistance Program

 

Pharmaceutical Company

Roche Pharmaceuticals

Program Name

Fuzeon Reimbursment Assistance Program

Program Address

PO Box 221769
Charlotte NC, 28222

Medicines On Program

Fuzeon

Phone Number

866.694.6670

Guidelines and Notes

The patient must enroll in The Progressive Distrubution Program (PDP) first, There is a application for this that is completed by the doctor and patient. On this application is a question about insurance coverage. If the patient is in need, then the patient is transferred over to the Reimbursement Assistance Program. First the program tries to find alternative coverage. If no alternative coverage is found, then another application is sent out to the doctor's office.

Initiating
Enrollment

The doctor must call to get an enrollment application for PDP. If the patient is in need to company will contact the doctor.

Health Provider's Role

The doctor needs to fill out a section of the application and sign it.

Patient's Role

The patient needs to fill out a section, sign the application and attach proof of income.

How Dispensed

The medication is sent either to the patient's home or doctor's office.

Amount Dispensed

The medication is sent in a one month kit at a time.

Refills

Shipments are sent out by the company for 6 months. The company will contact the patient when the six months is up and send a new application.

Limit

Indefinitely

 

74. Gabitril Patient Assistance Program

 

Pharmaceutical Company

Cephalon, Inc.

Program Name

Gabitril Patient Assistance Program

Program Address

PO Box 430
Hackettstown, NJ 07840

Medicines On Program

Gabitril, 12mg, Gabitril, 16mg, Gabitril, 2mg, Gabitril, 4mg

Phone Number

800-511-2120

Guidelines and Notes

The patient must be a US citizen, with an income equal or less than $17,960 for a family of one, and $24,240 for a family of two.

Initiating
Enrollment

Someone from the doctor's office should call for an application, it will be faxed out. The blank application can be photocopied.

Health Provider's Role

The doctor must fill out a section and sign the application.

Patient's Role

Patient needs to attach proof of income (list on application) and fill out a section and sign.

How Dispensed

Coupons are sent to the patient. These coupons are taken with a prescription to a pharmacy for medication.

Amount Dispensed

The coupons are good for a 90 days supply.

Refills

After 3 months, company automatically sends another coupon out. if the coupons do not arrive, the patient can call for some to be sent. A new application is needed after one year, with new proof of income.

Limit

Indefinitely

 

 

 

75. Galderma Laboratories Patient Assitance Program

 

Pharmaceutical Company

Galderma Laboratories

Program Name

Galderma Laboratories Patient Assitance Program

Program Address

14501 North Freeway
Fort Worth TX 76177

Medicines On Program

Capex Shampoo Topical Shampoo 0.01%, Differin Gel 0.1%, MetroGel Topical Gel 0.75%, MetroLotion Topical Lotion 0.75%, Rozex Topical 0.75%, TriLuma Cream 30 gram

Phone Number

866-730-5074

Guidelines and Notes

Any patient who, in the judgement of the physician or dermatologist, is in need of assistance and who doesn't qualify for state or federal assistance can apply. Patient cannot have any prescription insurance.

Initiating
Enrollment

The patient or the doctor can call to get an application faxed to the doctor's office. Completed applicaiton and prescription should be mailed back to the company.

Health Provider's Role

The doctor must fill out a section, sign and attach a prescription.

Patient's Role

The patient needs to provide the needed information to the doctor (minimal information.) The patient does not need to sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

One tube of the requested medication is sent at one time. (Approximately 3-4 weeks)

Refills

For refills a new application is needed with the 'repeat request' box checked on the application.

Limit

Unspecified

 

 

76. Gammassist Program

 

Pharmaceutical Company

Baxter Healthcare Corporation

Program Name

Gammassist Program

Program Address

750 The City Drive, Ste 210
Orange, CA 92868-4940

Medicines On Program

Gammagard

Phone Number

1-800-888-4502

Guidelines and Notes

This is a safety net program for people currently insured and on Gammagaurd. Once enrolled, every quarter a coupon is sent to the patient, with a limit at 12 coupons. If, after the first year, the patient loses their insurance then the coupons can be redeemed (up to three coupons a year.) for Gammagaurd.

Initiating
Enrollment

The patient can go to the website www.immunedisease.com or call the above number to get an application.

Health Provider's Role

The doctor doesn't need to do anything for this program.

Patient's Role

The patient needs to give basic information.

How Dispensed

The coupon is sent to the patient's home. When coupons are redeemed the patient needs to send the coupon back to the company.

Amount Dispensed

The coupon is based on usage up to 150 grams.

Refills

Not Applicable

Limit

Not Applicable

 

 

 

 

77. Gemzar Patient Assitance Program

 

Pharmaceutical Company

Eli Lilly & Company

Program Name

Gemzar Patient Assitance Program

Program Address


Address not needed; all information is exchanged with program via fax.

Medicines On Program

Gemzar

Phone Number

888-443-6927, #1

Guidelines and Notes

They have a reimbursement program for patients with insurance who have been denied coverage for Gemzar and a program for patients with no insurance. Patients with no insurance must first meet their income guidelines which they will not disclose. And the patient must be still taking the medication or about to start taking the medication. Also, to apply for either program, patient must currently be in outpatient treatment.

Initiating
Enrollment

Provider must call. They screen for eligibility over the phone and then fax the patient's application to the provider. The completed application should be faxed back.

Health Provider's Role

Doctor completes and signs a section of the application. If applying for a patient who's been denied insurance coverage, doctor submits denial letters and program assists with appeals.

Patient's Role

The patient must fill out a section of the application and answer fanancial and insurance questions and sign the application. The patient must also provide proof of income.

How Dispensed

The company sends medication to provider's office.

Amount Dispensed

Depends on dosing regimen.

Refills

For each date of service the doctor's office must send in the dose tracking form and the flow sheet to get another dosage.

Limit

Indefinitely

 

78. Genetech Access To Care Foundation (Growth Hormones)

 

Pharmaceutical Company

Genentech, Inc.

Program Name

 

Program Address

1 DNA Way, Mail Stop 210
So. San Francisco CA 94080

Medicines On Program

Nutropin, Nutropin AQ, Nutropin Depot, Protropin

Phone Number

800-879-4747

Guidelines and Notes

The patient must have no insurance, or be under insured for the medication. There are two Statements of Medical Necessity and Authorization Forms, one for adults and one for children.

Initiating
Enrollment

The doctor must call for a Statement of Medical Necessity and Patient Authorization Form. It can also be downloaded from www.spoconline.com The doctor must fax the completed Statement and Authorization Form to the company who will decide if the patient is eligible. If the patient is eligible, than an applicaiton is sent to the patient.

Health Provider's Role

The doctor only needs to fill out the information on the Statement of Medical Necessity, it has a prescription section, and a place to sign. The first time the doctor enrolls a patient, the doctor must also enroll, using the Physician Profile (available on www.spoconline.com).

Patient's Role

The patient has to sign the Patient Authorization Form and fill out the application that is sent to her/his home.

How Dispensed

The medication is sent to either the patient's home or the doctor's office.

Amount Dispensed

Starts with a 30 day supply. After that up to a ninty day supply can be sent.

Refills

The patient needs to call two weeks before they run out to get a refill. Every year in May a new application is needed.

Limit

Unspecified.

 

79. Genentech Access to Care (Activase, TNKase & Cathflo)

 

Pharmaceutical Company

Genentech, Inc.

Program Name

Genentech Access to Care (Activase, TNKase & Cathflo)

Program Address

1 DNA Way, Mail Stop 210
So. San Francisco CA 94080

Medicines On Program

Activase, Cathflo 2 mg, TNKase

Phone Number

800-530-3083, Opt 1

Guidelines and Notes

The patient must have no insurance, and have a family income of less than $30,00. The diagnosis must be FDA approved, except for Cathflo. This is a drug replacement program.

Initiating
Enrollment

The facility, doctor or hospital calls to get an application which is faxed out. The completed application can be faxed back.

Health Provider's Role

Doctor needs to complete and sign a section of the application.

Patient's Role

The patient needs to give the provider information, but does not need to sign form.

How Dispensed

The medication is sent to the hospital or facility.

Amount Dispensed

The amount of medication depends on what is used for the patient. In case of large amounts the company may require proof of use.

Refills

Not applicable, since this is a replacement.

Limit

Unspecified.

 

80. Genentech Access To Care Foundation (Oncology Medications)

 

Pharmaceutical Company

Genentech, Inc.

Program Name

Genentech Access To Care Foundation (Oncology Medications)

Program Address

1 DNA Way, Mail Stop 210
So. San Francisco CA 94080

Medicines On Program

Herceptin, Rituxan

Phone Number

800-530-3083, opt 1

Guidelines and Notes

The patient must have no insurance, and have a family income of less than $75,000. The diagnosis must be FDA approved, if the diagnosis is not FDA approved, speak to the company. This is a drug replacement program.

Initiating
Enrollment

The provider's office can call to get an application faxed to the office or anyone can go online www.spoconline.com. The completed application should be faxed back.

Health Provider's Role

Doctor needs to complete and sign a section of the application.

Patient's Role

The patient needs to provide information and sign the application.

How Dispensed

The medication is sent to the doctor's office or the hopital.

Amount Dispensed

The amount of medication depends on what is used for the patient.

Refills

Not applicable, since this is a replacement.

Limit

Unspecified.

 

 

 

81. Genentech Access to Care (Raptiva)

 

Pharmaceutical Company

Genentech, Inc.

Program Name

Genentech Access to Care (Raptiva)

Program Address

Not Applicable

Medicines On Program

Raptiva

Phone Number

877-727-8482

Guidelines and Notes

The patient must have no insurance, or be under insured for the medication.

Initiating
Enrollment

The doctor must call for a Statement of Medical Necessity and Patient Authorization Form. It can also be downloaded from www.spoconline.com The doctor must fax the completed Statement and Authorization Form to the company who will decide if the patient is eligible. If the patient is eligible, than an applicaiton is sent to the patient.

Health Provider's Role

The doctor only needs to fill out the information on the Statement of Medical Necessity, it has a prescription section, and a place to sign. The first time the doctor enrolls a patient, the doctor must also enroll, using the Physician Profile (available on www.spoconline.com).

Patient's Role

The patient has to sign the Patient Authorization Form and fill out the application that is sent to her/his home.

How Dispensed

The medication is sent to either the patient's home or the doctor's office.

Amount Dispensed

Starts with a 30 day supply. After that up to a ninty day supply can be sent.

Refills

The patient needs to call two weeks before they run out to get a refill. Every year in May a new application is needed.

Limit

Unspecified.

 

82. Genentech Access to Care (Xolair)

 

Pharmaceutical Company

Genentech, Inc.

Program Name

Genentech Access to Care (Xolair)

Program Address

Not Applicable

Medicines On Program

Xolair

Phone Number

800.704.6614

Guidelines and Notes

The patient must have no insurance, and meet financial guidelines that are not disclosed. The diagnosis must be FDA approved, if the diagnosis is not FDA approved, speak to the company.

Initiating
Enrollment

The doctor must call for a Statement of Medical Necessity and Patient Authorization Form. It can also be downloaded from www.spoconline.com The doctor must fax the completed Statement and Authorization to one of the following speciality pharmacy companies who will send it on to Genentech. 1) Care Market: (f) 800-323-2445 (p) 800-237-2767 2) Curascript (f) 888-773-78386 (p) 888-281-5464 3) NovaFactor (f) 866-531-1025 (p) 866-839-2162 4) Option Care (f) 888-570-4700 (p) 888-282-5166 5) Priority Healthcare (f) 866-269-3113 (p) 866-757-3929 If the patient is eligible for the program then an application is sent to the patient.

Health Provider's Role

The doctor only needs to fill out the information on the Statement of Medical Necessity, it has a prescription section, and a place to sign. The first time the doctor enrolls a patient, the doctor must also enroll, using the Physician Profile (available on www.spoconline.com).

Patient's Role

The patient has to sign the Patient Authorization Form and fill out the application that is sent to her/his home.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

Usually a one month treatment is sent at one time.

Refills

The doctor's office call for refills. Once a year a new application is needed.

Limit

Indefinitely.

 

83. Genentech Endowment for Cystic Fibrosis

 

Pharmaceutical Company

Genentech, Inc.

Program Name

Genentech Endowment for Cystic Fibrosis

Program Address

PO Box 222157
Charlotte, NC 28222-2157

Medicines On Program

Pulmozyme

Phone Number

800-297-5557

Guidelines and Notes

They encourage patients to call them while completing the application. They can be reached between 9 and 5pm EST. Patient must have Cystic Fibrosis. Patient and physician fill out application. Patient must either have no insurance or not be able to afford the co-payments. The company looks at out of pocket medical expenses, household income, but the guidelines are not disclosed. Program may provide full or partial assistance.

Initiating
Enrollment

Anyone can call for application or get one from www.genentechcfendowment.org. Completed applications and documentation can be mailed or faxed. Both patients and physicians will be notified in writing about eligibility.

Health Provider's Role

The doctor must complete a section and sign a page of the application.

Patient's Role

Patient (or guardian) signature required. Income and insurance information required. Copy of most recent tax return, and denials for public assistance (if appropriate) or insurance denial for Pulmozyme needed.

How Dispensed

Once accepted into the program, s/he is sent three vouchers at once, one voucher per month to be taken to the pharmacy.

Amount Dispensed

There is no set limit or amount of medication sent.

Refills

Every three months a new set of vouchers is sent out. After a year a whole new application is needed.

Limit

Indefinitely

 

84. Geodon Patient Assistance Program

 

Pharmaceutical Company

Pfizer, Inc.

Program Name

Geodon Patient Assistance Program

Program Address

PO Box 52119
Phoenix, AZ 85072

Medicines On Program

Geodon 20mg, Geodon 40mg, Geodon 60mg, Geodon 80mg

Phone Number

866-443-6366

Guidelines and Notes

The patient must be a US resident, have no prescription coverage, or have reached their limit. The patient must also fall below income guildelines that they don't release.

Initiating
Enrollment

The doctor or social worker should call to get an application, which will be faxed out. The blank application can be photocopied. The completed application can be faxed or mailed back to the company. Provider is notified if the patient is accepted.

Health Provider's Role

Provider completes prescriber information and checks off dose required.

Patient's Role

The patient must fill out sections on insurance, income and sign the application.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

Upon acceptance, a 30 day supply is sent out while a case manager tries to find another payer source. After the initial 30 day supply, and if there is no alternative source another 60 day supply is sent out.

Refills

A form will be sent to the doctor's office that is required every 90 days for refills. After a year a whole new application is needed.

Limit

Unspecified

 

85. Gilead Commitment to Access

 

Pharmaceutical Company

Gilead Sciences

Program Name

Gilead Commitment to Access

Program Address

PO Box 221887
Charlotte, NC 28222-1887

Medicines On Program

DaunoXome, Emtriva, Hepsera, Viread, Vistide

Phone Number

800-226-2056

Fax Number

800-216-6857

Initiating
Enrollment

Anyone can call to get an application, which can be faxed or mailed out. The blank application can be copied. The completed application can be faxed or mailed back to the company.

Health Provider's Role

The doctor must fill out a section and attach a prescription.

Patient's Role

The patient must fill out a section of the application and sign. The company may request documentation.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The medication is sent in a one month supply.

Refills

After 90 days a Verfication Letter is sent to both the doctor and the patient, those forms are sent back in with a new prescription to get another 90 days worth. After one year a new application is needed.

Limit

Not specified.

 

86. Glaxo-SmithKline Commitment to Access

 

Pharmaceutical Company

GlaxoSmithKline

Program Name

Glaxo-SmithKline Commitment to Access

Program Address

PO Box 29038
Phoenix, AZ 85038-9038

Medicines On Program

Bexxar, Hycamptin for injection, Leukeran 2mg (Sugar Coated Tablets), Myleran 2-mg Scored Tablets, Navelbine Injection, Tabloid 40-mg Scored Tablet, Zofran Injection , Zofran Injection Premixed, Zofran Oral Solution, Zofran Orally Disintegrating Tablets 4 mg, Zofran Orally Disintegrating Tablets 8 mg, Zofran Tablets 24mg, Zofran Tablets 4mg, Zofran Tablets 8 mg

Phone Number

1-866-265-6491

Guidelines and Notes

The patient must be a US resident, have a household income not more that 350% of the Federal Poverty Level and have no prescription insurance. GlaxoSmithKline requests that an "Advocate" be the contact person for the patient throughout the entire process. The advocate can be any healthcare worker involved in the patient's care (i.e., doctor, nurse, social worker, or someone in the healthcare office or facility).

Initiating
Enrollment

An advocate must call for an application, which will be faxed or mailed out with a patient number on the application. The advocate can also start the enrollment process online at commitmenttoaccess.gsk.com. The application cannot be copied. After the patient and advocate fill out the application, the advocate must call the company to complete the enrollment process.

Health Provider's Role

The doctor must complete a section, attach a prescription and sign the application. If the appliaction is accepted then the prescription must be faxed to 1-800-750-9832, please indicate "Attention: Direct Ship Specialist."

Patient's Role

The patient's role is to complete a section of the application that asks questions about insurance and monthly gross income. When completed, the patient will sign the application and attach proof of income.

How Dispensed

Sends medicine to doctor's office within a week of approval.

Amount Dispensed

The medication will be sent in a 30 day supply.

Refills

To initiate the next 30-day shipment, the advocate must call five to seven business days before the medication runs out. Every year, the patient and advocate need to complete a new application. GlaxoSmithKline will send a reminder letter whenever they need new information or documentation.

Limit

Indefinite

 

87. GlaxoSmithKline Bridges To Access

 

Pharmaceutical Company

GlaxoSmithKline

Program Name

GlaxoSmithKline Bridges To Access

Program Address

PO Box 29038
Phoenix, Az 85038

Medicines On Program

Aclovate cream .05%, Aclovate ointment .05%, Advair Diskus 100/50, Advair Diskus 250/50, Advair Diskus 500/50, Agenerase Capsules 150 mg, Agenerase Capsules 50 mg, Agenerase Oral Solution, Amerge Tablets 1mg, Amerge Tablets 2.5mg, Amoxil Capsules 500mg, Amoxil Chewable Tablets 200mg, Amoxil Chewable Tablets 250 mg, Amoxil For Oral Suspension 250mg/5ml, Amoxil For Oral Suspension 400mg/5ml, Amoxil Powder 50mg/ml, Amoxil Powder for Oral Suspension 125mg/5ml, Amoxil Powder for Oral Suspension 200mg/5ml, Amoxil Tablets 400 mg, Amoxil Tablets 500 mg, Amoxil Tablets 875 mg, Augmentin ES-60O, Augmentin Oral Suspension -Chewable Tablets, Augmentin Powder for Oral Suspension 200mg/5ml , Augmentin Powder for Oral Suspension 250mg/5 ml, Augmentin Tablets, Augmentin XR, Avandia Tablets 2mg, Avandia Tablets 4mg, Avandia Tablets 8mg, Avanvamet Tablets, Avodart, Bactroban Creme, Bactroban Ointment, Beconase AQ Nasal Spray .042%, Ceftin Oral Suspension 125mg, Ceftin Oral Suspension 125mg/5ml, Ceftin Oral Suspension 250mg/5ml, Ceftin Tablets 125mg, Ceftin Tablets 250mg, Ceftin Tablets 300mg, Ceftin Tablets 500mg, Ceftin Tablets 601.44 mg, Combivir, Coreg Tablets 12.5mg, Coreg Tablets 25mg, Coreg Tablets 3.125mg, Coreg Tablets 6.25mg, Cultivate Cream .05%, Cultivate Ointment .005%, Daraprim 25 mg Scored Tablets, Dexedrine Spansule Capsules, Dexedrine Tablets, Dyazide Capsules 25mg/37.5mg, Epivir Oral Suspension, Epivir Tablets 150mg, Epivir Tablets 300mg, Epivir-HBV Oral Suspension, Epivir-HBV Tablets, Eskalith CR Capsules 300 mg, Eskalith CR Tablets 450 mg, Flonase Nasal Spray 50 mcg., Flovent 110 mcg, Flovent 220 mcg, Flovent 44 mcg, Flovent Rotadisk 100 mcg, Flovent Rotadisk 250 mcg, Flovent Rotadisk 50 mcg, Fortaz Injection 1gm/vil, Fortaz Injection 2gm/vil, Fortaz Injection 500mg/vil, Fortaz Injection 6gm/vil, Imitrex injectable, Imitrex nasal spray 20mg/unit, Imitrex nasal spray 5mg/unit, Imitrex tablets 100 mg, Imitrex tablets 25 mg, Imitrex tablets 50 mg, Lamictal Chewable Dispersible Tablets 25mg, Lamictal Chewable Dispersible Tablets 2mg, Lamictal Chewable Dispersible Tablets 5 mg, Lamictal Tablets 100 mg, Lamictal Tablets 200 mg, Lamictal Tablets 25 mg, Lanoxicaps 100 mcg Imprint B2C (yellow), Lanoxicaps 200 mcg Imprint C2C (Green), Lanoxicaps 50 mcg Imprint A2C (Red), Lanoxin Elixir Pediatric 50 mcg, Lanoxin Tablets, Lotronex, Malarone Pedatric Tablets, Malarone Tablets 250mg;100mg, Malarone Tablets 62.5mg;25mg, Mepron, Oxistat Cream 1%, Oxistat Lotion 1%, Parnate Tablets 10mg, Paxil CR 12.5 mg, Paxil CR 37.5 mg, Paxil Oral Suspension, Paxil Tablets 10 mg, Paxil Tablets 20 mg, Paxil Tablets 40 mg, Relafen 500mg , Relafen 750mg , Relenza Powder for Inhalation, Requip 0.25mg, Requip 0.5 mg, Requip 1 mg, Requip 2 mg, Requip 3 mg, Requip 4 mg, Requip 5 mg, Retrovir Capsules, Retrovir Syrup, Retrovir Tablets, Serevent Diskus Powder for Inhalation 50mcg, Tagamet Tablets 300mg, Tagamet Tablets 400mg, Tagamet Tablets 800mg, Temovate Cream , Temovate E Emollient, Temovate Emollient, Temovate Gel, Temovate Ointment, Temovate Scalp Application, Timentin, Timentin Injection, Trizivir, Valtrex Capsules, Ventolin HFA, Wellbutrin SR, Wellbutrin Tablets, Wellbutrin XL Tablets, Zantac 150 EFFERdose Tablets, Zantac 150 tablets, Zantac 300 tablets, Zantac Injection , Zantac Injection Premixed, Zantac Syrup, Ziagen oral solution, Ziagen tablets, Zinacef, Zovirax capsules, Zovirax suspension, Zovirax tablets, Zyban SR Tablets

Phone Number

866-728-4368

Guidelines and Notes

The patient must be a US resident, have a household income not more that 250% of the Federal Poverty Level for a multiple income household and not more than $25,000 for a single income household. The patient also can not have any prescription insurance. The company requests that an 'Advocate' be the contact person for the patient, throughout the entire process. The advocate can be any healthcare worker invovled in the patient's care. (Phyisician, nurse, social worker or some in the healthcare office or facility.)

Initiating
Enrollment

The advocate calls for an application and it will be faxed or mailed out with a patient ID number. Or the enrollment process may be started on line at bridgestoaccess.gsk.com. After the application is filled out the advocate must call the company to start the enrollment process. If the patient is accepted during the enrollment phone call the coupon attached to the form is activated for a 60 day supply of medication with a small co-pay. The completed applicatin must also be mailed in.

Health Provider's Role

Doctor completes, and signs the application. A prescription for 3 90 day refills. The advocate must also complete a section and sign the form.

Patient's Role

The patient must fill out a detailed section on financial and income information. The patient must also provide proof of income and insurance information.

How Dispensed

After the initial 60 day supply that is recieved using the coupon, the medication is shipped to the patient's house. The following drugs must be picked up at a pharmacy: Relenza, Dexedrine, and Lotronex.

Amount Dispensed

After the initial 60 day supply, the medication is given out in a 90 day supply.

Refills

To get the 90 day refill the patient must call 1-866-PATIENT to request the next shipment. After six months the Advocate will recieve a form to reauthorize the patient for another six months. After one year a Re-enrollment form is sent to the advocate to re-enrolll the patient for another year.

Limit

Indefinitely

 

88. Glenwood Compassionate Drug Program

 

Pharmaceutical Company

Glenwood & Western Medical

Program Name

Glenwood Compassionate Drug Program

Program Address

Glenwood LLC
111 Cedar Lane
Englewood NJ, 07631

Medicines On Program

Potaba

Phone Number

800-542-0772 ext 1

Guidelines and Notes

Enrollement for this program is a case by case. The company limits to only 20 patients nationwide at any given time, but rarely have 20 people on the program. Patients must be in financial need and be willing to take what they consider the full therapeutic dosage (12 grams a day.)

Initiating
Enrollment

Any health care professional can call for the application. The application can be copied. Completed applcation can be faxed back.

Health Provider's Role

The doctor must fill out a section, sign and attach a prescription and their state license number. A personal letter is needed only if the patient does not meet the two outlined criteria. The letter needs to explain why the patient should still be eligible.

Patient's Role

Needs to sign and fill out a section. They must also send in proof of income for all the family members.

How Dispensed

Medication is shipped to the doctor's office.

Amount Dispensed

Medication is sent out for three months.

Refills

When the medication is running low, the doctor's calls for refills.

Limit

Indefinetly.

 

89. Hectorol Patient Assistance Program

 

Pharmaceutical Company

Bone Care International, Inc.

Program Name

Hectorol Patient Assistance Program

Program Address

Bone Care Center
1600 Aspen Commons
Middleton, WI 53562

Medicines On Program

Hectorol Capsules 2.5 mcg

Phone Number

888.389.3300

Guidelines and Notes

A patient must meet financial guidelines that are not disclosed. The patient must also be a US resident, with no medical insurance and be ineligible for government assistance. If the patient is eligble for Medicaid benefits, they must have reached their cap or not be covered for the medication.

Initiating
Enrollment

Anyone can call for an application or go to the website, www.hectorol.com and applications will be automatically mailed out or faxed out. The completed application mailed or faxed back to the company.

Health Provider's Role

The doctor must fill out a section, sign and attach a copy of their state license certificate. The perscription is built iinto the application.

Patient's Role

The patient must fill out a section with insurance information and sign the application. The patient must also attach financial documents (SSI, W2 or IRS forms.)

How Dispensed

The medication is sent to the doctor's office within two weeks.

Amount Dispensed

A three month supply is sent out.

Refills

For each refill a Prescription Verification Form must be filled out by the doctor and faxed back with a new prescription. All applications expire on December 31, and then a new application is needed.

Limit

Indefinitely

 

90. Helping Hands Program for Mead Johnson Nutritionals

 

Pharmaceutical Company

Mead Johnson Nutritionals

Program Name

Helping Hands Program for Mead Johnson Nutritionals

Program Address

2400 W. Lloyd Expressway
Evansville, IN 47721

Medicines On Program

Enfacare AR Liplil, Enfamil Pregestimil, Nutramigen

Phone Number

800-222-9123

Guidelines and Notes

They are a division of Bristol Myers Squibb. For infants using a very specialized formulas. Baby must be under one year of age. There are many factors involved in determining eligibility for this program, which are not disclosed, but household income is an important factor.

Initiating
Enrollment

Doctor calls sales representative who will determine if family qualifies for assistance. The sales rep will then contact the patient to

Health Provider's Role

Minimal - makes call to company representative.

Patient's Role

Let physician know they can't afford the formula.

How Dispensed

Usually sent to family.

Amount Dispensed

Not specified.

Refills

Have provider call again. Refills are available

Limit

Unspecified

 

91. IVAX Patient Assistance Program for Clozapine

 

Pharmaceutical Company

IVAX Pharmaceuticals, Inc.

Program Name

IVAX Patient Assistance Program for Clozapine

Program Address

IVAX Patient Assistance Program for Clozapine
50 NW 176th Street
Butler Building, Second Floor
Miami, Florida 33169

Medicines On Program

Clozapine

Phone Number

800-507-8334

Fax Number

800-507-8334

Initiating
Enrollment

Both the Registration form and the Patient Assistant Program application can be copied, and faxed out to people. Completed forms and applications can also be faxed back.

Health Provider's Role

The physican must fill out a section and sign it. The pharmacy that the medication will sent to must also fill out a section. The pharmacy must be willing to distribute the medication at no charge.

Patient's Role

Minimal information required, would be on-file for the Registration form.

How Dispensed

The medication is sent to the pharmacy indicated on the application.

Amount Dispensed

A 12 week supply is sent out, that is given to the patient once or twice a week.

Refills

With the medication there is Refill Form that the pharmacist fills out and sends back for refills.

Limit

Indefinitely

 

92. Janssen Patient Assistance Program

 

Pharmaceutical Company

Janssen Pharmaceutica

Program Name

Janssen Patient Assistance Program

Program Address

PO Box 221857
Charlotte NC 28222-1857

Medicines On Program

Duragesic CII, Nizoral Tablets, Reminyl Oral Solution, Reminyl Tablets, Sporanox Capsules, Sporanox Oral Solution

Phone Number

800-652-6227, option #2

Guidelines and Notes

If a patient cannot afford the drug, an application should be completed. They have financial guildelines that are not disclosed, but based on the Federal Guildelines. But there are other factors that the company takes into account.

Initiating
Enrollment

Anyone can call for application. They will fax it and it can be copied. The completed application can be mailed or faxed to the company.

Health Provider's Role

The doctor must complete a section of the application, and sign it.

Patient's Role

The patient must provide basic information including insurance and financial information. The patient must also provide most recent tax form, if taxed were filed.

How Dispensed

The medication is sent to the doctor's office except for Duragesic, Reminyl. These two work on a pharmacy card that is sent to the patient.

Amount Dispensed

The medications are send in a 30 day supply. The pharmacy card is good for a 30 day supply at one time.

Refills

The medication is automatically sent to the doctor's office every month. Initial application is good for 6 months. Re-apply in same manner every 6 months.

Limit

Indefinitely

 

93. Kadian Patient Assistance Program

 

Pharmaceutical Company

Alpharma Pharmaceuticals

Program Address

PO Box 66554
St. Louis MO 63166-6554

Medicines On Program

Kadian C-II

Phone Number

866-884-5907

Application

Click here to download PDF

Guidelines and Notes

Medication is provided at no charge to needy patients. The patient no prescription coverage, US citizen, financial guidelines that are not disclosed. Make sure every space on application is either completed or marked "N/A" or "none"; incomplete applications won't be processed. There is a five dollar montly fee to pay for the shipping.

Initiating
Enrollment

Company has an automatic fax system to send faxes to the doctor's office. The blank application can be copied. The completed application must be mailed back to the company.

Health Provider's Role

The doctor must fill in a section and sign the application and attach a prescription.

Patient's Role

The patient needs to fill out a section with detailed financial and income information. The patient also must sign the application. Every month the patient must send a $5 money order for the shipment charges.

How Dispensed

Patient will be notified of status of application. If approved, prescription is submitted and medication is shipped directly to patient.

Amount Dispensed

One month supply at a time is sent.

Refills

A new prescription and $5 money order is needed for the next month supply. Every year a new application is needed.

Limit

Patient can stay on program for up to 2 years

 

94. Keppra Patient Assistance Program

 

Pharmaceutical Company

UCB Pharma, Inc.

Program Name

Keppra Patient Assistance Program

Program Address

1950 Lake Park Drive
Smyrna, GA 30080

Medicines On Program

Keppra

Phone Number

800-477-7877 x7

Guidelines and Notes

The patient must not have any prescription coverage, or be eligible for Medicaid benefits. Individual patients must not have an annual income greater than $15,000. A family with dependents must not exceed $25,000.

Initiating
Enrollment

The patient or provider can call for an application, which is faxed. The blank application can be copied. The completed application must be mailed back.

Health Provider's Role

The doctor must fill out a section of the application, sign and attach a 6 month prescription.

Patient's Role

The patient must also fill out a section of the application and sign.

How Dispensed

To the doctor's office. Allow 4 to 6 weeks for delivery.

Amount Dispensed

An six month supply is sent at one time. The program will not supply quantities in excess of the maximum approved daily dose (3000 mg/day.)

Refills

Every six months a new application is required.

Limit

Not specified.

 

95. King Kare Patient Assistance Program

 

Pharmaceutical Company

King Pharmaceuticals

Program Name

King Kare Patient Assistance Program

Program Address

100 18th Street
Bristol, TN 37620

Medicines On Program

Altace Capsules 1.25 mg, Altace Capsules 10 mg, Altace Capsules 2.5 mg, Altace Capsules 5 mg, Anusol -HC 25 mg Suppository, Anusol- HC 2.5% Cream, Corgard 120mg, Corgard 160mg, Corgard 40mg, Corzide, Cytomel 25mcg, Cytomel 50mcg, Cytomel 5mcg, Florinef, Intal Inhaler 14.2 gm, Intal Nebulizer Solution 20mg/2 ml, Kemadrin Tablets 5 mg, Levoxyl 300mcg, Levoxyl 100 mcg, Levoxyl 112 mcg, Levoxyl 125 mcg, Levoxyl 137 mcg, Levoxyl 150 mcg, Levoxyl 175 mcg, Levoxyl 200 mcg, Levoxyl 25 mcg, Levoxyl 50 mcg, Levoxyl 88 mcg, Lorabid 200 mg Capsules, Lorabid 400 mg Capsules, Menest 2.5 mg tablets, Menest Tablets 0.3 mg, Menest Tablets 0.625 mg, PreFest 1 mg , Procanbid 1000 mg tablets, Procanbid 500 mg tablets, Proctocort 1% cream, Proctocort 30 mg suppositories, Quibron Capsules 150 mg, Quibron-T Accudose Tablets 300 mg, Quibron-T/SR Accudose Tablets 15 mg, Skelaxin, Tapazole Tablets 10mg, Tapazole Tablets 5 mg, Thalitone Tablets 15 mg, Tilade, Viroptic 1% ophthalmic solution

Phone Number

1-877-546-5332

Guidelines and Notes

This program is temporarily closed to new applications. The program may be back and running again in a few months. The patient must be a US resident, has no prescription insurance, both public or private. The patient must also meet the financial guidelines that not disclosed.

Initiating
Enrollment

Anyone can call for an application but they will only fax the application to the doctor's office. The blank application can be copied. The completed application must be mailed back. The most recent application has the date 02-27-2004. (Form #278-R01)

Health Provider's Role

A physician must fill out a section including State License number and sign off that the patient is in need. The signature must be an original. The application has a built in prescription.

Patient's Role

The patient must provide monthly household income and sign the application. The patient must provide proof of US citizenship if the patient has no social security number. The patient is also asked to provide proof of income.

How Dispensed

The medication is sent to the physician's office.

Amount Dispensed

A three month supply is sent to the doctor's office.

Refills

For another 3 month supply another application is required.

Limit

Not Applicable

 

96. Kos Pharmaceuticals Patient Assistance Program

 

Pharmaceutical Company

Kos Pharmaceuticals

Program Name

Kos Pharmaceuticals Patient Assistance Program

Program Address

2200 N. Commerce Parkway, Ste 300
Weston, FL 33326

Medicines On Program

Advicor ER Tablets 20mg/1000mg, Advicor ER Tablets 20mg/500mg, Azmacort Inhaler, Niaspan 1000 mg, Niaspan 500 mg, Niaspan 750mg

Phone Number

1-888-206-7015, ext 2

Guidelines and Notes

The patient must not qualify for government assistance or have any third party insurance coverage. not disclosed. Assume that it will take three weeks for shipping.

Initiating
Enrollment

The provider needs to fax a request to the company to get an application. The docotor's name, fax number and telphone number are required for an application. THe blank application can be copied The completed application can be faxed or mailed back.

Health Provider's Role

A licensed physician must fill in a section including state license number and attach a prescription up to three months.

Patient's Role

The patient (or legal guardian) must fill out a section and sign. The patient must also attach 1040 tax form or some sort of documentation of financial support.

How Dispensed

The medication is sent to the doctor's office, in about three weeks.

Amount Dispensed

A shipment of 3 months is sent out.

Refills

A new prescription is needed for refills. Once a year a new application is needed.

Limit

Indefinitely.

 

97. Ligand Assistance Program

 

Pharmaceutical Company

Ligand Pharmaceuticals

Program Name

Ligand Assistance Program

Program Address

PO Box 222197
Charlotte, NC 28222-2197

Medicines On Program

ONTAK 2 mL vial, Panretin Gel 60gm, Targretin capsules 75mg, Targretin Gel 60gm Tube

Phone Number

877-654-4263

Guidelines and Notes

Patient must be unable to purchase medicine and cannot have prescription coverage for the medication. The patient must meet income guildelines that are not disclosed. Once the application is received, they will make a determination of eligibility within 48 hours and notify provider.

Initiating
Enrollment

Anyone can call for an application, it will faxed out to the doctor's office. The blank application can copied. The completed application can be faxed or mailed.

Health Provider's Role

Doctor must complete a section of the application and sign. The doctor must also attach a prescription for the medication.

Patient's Role

Patient must fill out a section with detailed financial and insurance information needed and must sign.

How Dispensed

The medication is sent to the doctor's office.

Amount Dispensed

The amount sent depends on the patient's need, but usually a one month supply.

Refills

The company will fax a Verification Form to the doctor's office and once that is filled out and returned another shipment is sent out. Once a year a whole new application is needed.

Limit