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

Aptevo Therapeutics Reimbursement and Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Aptevo Therapeutics

PO Box 1041
Morristown, NJ 07962

TEL: 973-656-2626


FAX: 973-644-2361
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

Aptevo Therapeutics Reimbursement and Patient Assistance Program Application

Aptevo Therapeutics General Program Information

 

Brand Name Medications Covered

 
  • HepaGam B
  • WinRho SDF
  • Varizig
 

Generic Name

 
  • immune globulin; human varicella zoster
  • immune globulin; rh
  • immune globulin; intravenous (human) hepatitis B
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for the requested medication, be ineligible for federal or state programs
Those with Part D Eligible? No, must be ineligible
Income At or below 200% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Call or download
Receiving Faxed or mailed
Returning Fax or mail
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Health care provider notified via fax
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office
Delivery Time Within a week
Refill Process New application process required
Limit Not specified
Re-application Every 3 months new application required
   

Additional Information


Updated August 11, 2017