Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Lialda

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

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Lialda ()
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Determined case by case
Income At or below 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 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 and sign
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

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 June 03, 2015


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

Lialda

Shire Cares

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

Provided by: Shire Pharmaceuticals

Shire Cares Patient Assistance & Support Program
PO Box 5666
Louisville, KY 40255-0666

TEL: 888-227-3755


FAX: 877-922-7379
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Shire Cares Application

Shire Cares Application (Spanish)

 

Medications

  • Lialda (Tablet)
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be US citizen or legal entrant
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income and any insurance information
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 2-4 business days
   

Medication

Amount/Supply Not specified
Sent To Patient sent card to be used at pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information

Each Application will be considered on a case by case basis.

Updated June 29, 2015