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

Program 1 of 4   Scroll down to see them all.  Updated May 29, 2013 Back | Print Page

This is a copay assistance program.

CancerCare Co-Payment Assistance Foundation

Provided by:


CancerCare Co-Payment Assistance Foundation
275 Seventh Avenue
22nd Floor
New York, NY 10001

TEL: 866-552-6729


ALT PHONE: 866-55-COPAY
FAX: 212-712-8495
 Program Website

Languages Spoken: English

Patient assistance
applications

 

Medications

Adrucil Injection 2.5gm, 500gm, 500mg (fluorouracil)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Must have insurance
Those with Part D Eligible? Yes
Income At or below 250% of FPL
Diagnosis/Medical Criteria Must be diagnosed with one of the cancer types that the Foundation covers
US Residency Required? Must be treated by US Doctor
Obtaining Call
Receiving Mailed
Returning Mail, fax or email
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign
Decision Communicated Patient notified in writing
Decision Timeframe 7-10 business days
Amount/Supply Not applicable
Sent To Not applicable
Delivery Time Not applicable
Refill Process Not specified
Limit Not specified
Re-application New application yearly

Additional Information:

Cancers covered by the program include: Breast Cancer*, Breast Cancer (Metastatic)*, Colon or Colorectal Cancer*, Gastric Cancer, Glioblastoma, Head and Neck Cancer*, Non-Small Cell Lung Cancer*, Pancreatic Cancer, Prostate Cancer*, and Renal Cell Cancer*.

*starred cancers above have no funds as of 05/29/13. Contact the program to check if funding has been restored.

The Foundation will consider retroactive reimbursement on a case-by-case basis for first time applicants actively receiving chemotherapy treatment. However, the Foundation will only consider retroactive assistance for a date of service within 60 days prior to the date we approve your application.
Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.

Program 2 of 4   Scroll down to see them all.  Updated March 25, 2013 Back | Print Page

This is a copay assistance program.

Diplomat's Co-Pay Assistance Navigator Program

Provided by:


Diplomat Specialty Pharmacy
4100 S Saginaw St.
Flint, MI 48507

TEL: 877-977-9118 ext. 89864


ALT PHONE:
FAX: 810-282-0176
 Program Website

Languages Spoken: English

Patient assistance
applications


 

Medications

Adrucil Injection 2.5gm, 500gm, 500mg (fluorouracil)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income Determined case by case
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Yes
Obtaining Call or complete online
Receiving Faxed, mailed or complete online
Returning Mail or fax
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign and provide annual income information. Proof of income may be request by program at any time
Decision Communicated Patient and/or Doctor are notified
Decision Timeframe Within 1-2 business days
Amount/Supply Amount requested is sent
Sent To Patient's home
Delivery Time Once approved; within 2 business days
Refill Process Company contacts patient to arrange
Limit Varies per medication
Re-application Determined case by case

Additional Information:

Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the co-pay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie 
Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.

Program 3 of 4   Scroll down to see them all.  Updated May 10, 2013 Back | Print Page

This is a copay assistance program.

HealthWell Foundation Copay Program

Provided by:


HealthWell Foundation
P.O Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


ALT PHONE:
FAX: 800-282-7692
 Program Website

Languages Spoken: English, Others By Translation Service

Patient assistance
applications

 

Medications

Adrucil Injection 2.5gm, 500gm, 500mg (fluorouracil)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Less than 400% of FPL.may qualify. Cost of living in a particular city or state is considered.
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside in the US
Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Mail
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach proof of income
Decision Communicated Patient notified in writing
Decision Timeframe 3-5 business days
Amount/Supply Not applicable
Sent To
Delivery Time
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.
Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.

Program 4 of 4.  Updated February 12, 2013 Back | Print Page

This is a copay assistance program.

Patient Access Network Foundation

Provided by:


Patient Access Network Foundation
PO Box 221858
Charlotte, NC 28222

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
 Program Website

Languages Spoken: English, Spanish, Others By Translation Service

Patient assistance
applications


 

Medications

Adrucil Injection 50mg/ml (fluorouracil)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Must have insurance
Those with Part D Eligible? Yes
Income At or below 500% of FPL
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must reside and receive treatment in US
Obtaining Call or complete online
Receiving Sent out or may be completed online
Returning Fax, mail or submit online
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Complete section, sign, attach proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
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:

Call for most recent medications as the list is subject to change.



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