Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 5.
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SeaGen Secure Patient Assistance Program

This program provides medication at no cost.

Provided by: Seattle Genetics, Inc.

21823 30th Dr. SE
Bothell, WA 98021

TEL: 855-473-2873, opt. 2


FAX: 855-557-2480
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

SeaGen Secure PAP Enrollment Form

SeaGen Secure PAP Safety & Prescribing Information for Adcetris

 

Medications

  • Adcetris injection (brentuximab vedotin)
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Not applicable
Income Gross family household income at or less than $125,000
Diagnosis/Medical Criteria HL or NHL
US Residency Required? Must permanently reside in the US and be under the direct care of a US Physician
   

Application

Obtaining Call, download or apply online
Receiving Faxed, emailed or downloaded from website
Returning Email or fax
Doctor's Action Complete section
Applicant's Action Complete section and attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Varies. *see below for details
Sent To Clinic or hospital
Delivery Time Shipped overnight
Refill Process Doctor/Doctor's office must complete a Product Request Form per cycle
Limit None
Re-application New enrollment every 12 months
   

Additional Information

* If approved, one cycle will be shipped to the Provider for IV administration.

Patient can be on any line of therapy, any dosing schedule, and be pre or post Autologous Stem Cell Transplant.

Insurance benefits, claims assistance and/or other reimbursement help is offered.

Income and residency documentation required.


Updated July 07, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 5.
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Good Days Program

This is a copay assistance program

Provided by: Good Days from CDF

Attn: Enrollment
6900 Dallas Parkway
Suite #200
Plano, TX 75024

TEL: 877-968-7233


FAX: 214-570-3621
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Good Days Program Patient Enrollment Application (pages: 3-5)

Good Days Program Enrollment Information Pages (pages: 1 & 2)

 

Medications

  • Adcetris (brentuximab vedotin)
 

Eligibility Requirements   

Insurance Status Not specified
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax, mail or submit online
Doctor's Action Give prescription to patient
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Must re-enroll at end of calendar year
   

Additional Information

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.
Updated July 14, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 5.
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HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

 

Medications

  • Adcetris (brentuximab vedotin)
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
   

Medication

Amount/Supply Not applicable
Sent To Varies
Delivery Time Not specified
Refill Process Good for one year
Limit Not specified
Re-application New application every 12 months
   

Additional Information

This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease.

Call for most recent medications as the list is subject to change.
Updated May 22, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 5.
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Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • Adcetris (brentuximab vedotin)
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Once approved; shipped same day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application every 12 months
   

Additional Information

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

Call for most recent medications as the list is subject to change and the medication for which you are seeking assistance must treat the disease directly.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated June 29, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 5.
 

SeaGen Secure Commercial Co-insurance Assistance Program

This is a copay assistance program

Provided by: Seattle Genetics, Inc.

21823 30th Dr. SE
Bothell, WA 98021

TEL: 855-473-2873, opt. 2


FAX: 855-557-2480
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

SeaGen Secure Co-insurance Application

SeaGen Secure Co-insurance Safety & Prescribing Information for Adcetris

 

Medications

  • Adcetris injection (brentuximab vedotin)
 

Eligibility Requirements   

Insurance Status May have private/commercial insurance coverage (not a participant in federal or state-funded benefits program)
Those with Part D Eligible? No
Income Gross family household income at or less than $125,000
Diagnosis/Medical Criteria Must be used for on-label diagnosis
US Residency Required? Must permanently reside in the US and be under the direct care of a US Physician
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Doctor/Doctor's office must call
Applicant's Action Inform Doctor that he/she is in need
Decision Communicated Patient and Doctor are notified
Decision Timeframe Within 24-48 hours
   

Medication

Amount/Supply Not applicable
Sent To Doctor's office
Delivery Time Not applicable
Refill Process Not applicable
Limit None
Re-application New application yearly
   

Additional Information

Income and residency documentation required.


Updated July 07, 2017