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

Program 1 of 2.
Scroll down to see them all.
Updated February 20, 2014
Fuzeon T-20

Genentech Access to Care Foundation (HIV & Transplants)

This program provides brand name medications at no or low cost.

Provided by: Genentech, Inc.

P.O. Box 29064
Phoenix, AZ 85038

TEL: 888-754-7651


ALT PHONE:
FAX: 800-305-1830
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Genentech Patient Auth. and Notice of Release of Information (PAN); Cellcept & Valcyte

Genentech Patient Auth. and Notice of Release of Information (PAN); Cellcept & Valcyte (Spanish)

Genentech Statement of Medical Necessity - Cellcept

Genentech Statement of Medical Necessity - Valcyte

 

Medications

  • Fuzeon T-20 Injection 90/1mL (enfuvirtide)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? Determined case by case
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Not disclosed
US Residency Required? Must be treated by US licensed healthcare provider
   

Application

Obtaining Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete and sign statement of medical necessity
Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Varies
Sent To Patient's home, doctor's office, hospital or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information




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

Program 2 of 2. Updated April 11, 2014
Fuzeon T-20

Diplomat's Co-Pay Assistance Navigator Program

This is a copay assistance 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
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Diplomat Request of Financial Assistance Form

 

Medications

  • Fuzeon T-20 Injectable; Subcutaneous 90mg/vial (enfuvirtide)
 

Eligibility Requirements

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
   

Application

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
   

Medication

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 copay 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 
Contact program for Spanish application.