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Program 1 of 5.
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Afinitor

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Novartis Patient Assistance Foundation, Inc.

This program provides brand name medications at no or low cost

Provided by: Novartis Pharmaceuticals

PO Box 52029
Phoenix, AZ 85072-2029

TEL: 800-277-2254


FAX: 855-817-2711
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Novartis Patient Assistance Foundation, Inc. Enrollment Application

Novartis Patient Assistance Foundation, Inc. Enrollment Application (Spanish): Contact program

 

Medications

  • Afinitor (everolimus)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? Contact program for details.
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed
Returning Fax or mail
Doctor's Action Complete section, sign, attach prescription for 90 days
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Doctor notified via mailed letter
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient is sent card to be used at pharmacy
Delivery Time Not specified
Refill Process Refill/reorder form included with shipment
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information

For Focalin XR, Clozaril, and Ritalin LA, Clozarila pharmacy card will be issued. All other medication will be shipped directly to the physician.

*Additional products may be available. Please contact the program for a complete product listing. www.pap.novartis.com
Updated August 25, 2017


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Afinitor

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PANO (Novartis Patient Assistance Now Oncology)

This program provides brand name medications at no or low cost

Provided by: Novartis Pharmaceuticals

Novartis Patient Assistance Program
PO Box 66978
St. Louis, MO 63166-6978

TEL: 866-884-5906


ALT PHONE: 800-282-7630
FAX: 888-891-4924
Languages Spoken:

English

Program Website

 

Program Applications and Forms

PANO (Novartis Patient Assistance Now Oncology) Request Form

 

Medications

  • Afinitor (everolimus)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage
Those with Part D Eligible? Considered on exception basis
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Yes
   

Application

Obtaining Doctor must ask for service request
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 Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Patient must contact company
Limit None
Re-application New application yearly
   

Additional Information

Eligibility determined on a case-by-case basis.

Uninsured patients, call 1-866-884-5906
Patients with insurance, call 1-800-282-7630

This program also provides copay assistance up to $36,000 per year for Signifor and $9,600 per year for Sandostatin. Carcinoid tumor patients are now eligible.


Updated September 08, 2017


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Afinitor

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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

  • Afinitor (everolimus)
 

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


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Afinitor

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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

  • Afinitor (everolimus)
 

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


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Program 5 of 5.
 

Afinitor

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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

  • Afinitor (everolimus)
 

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