| 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 November 03, 2014 | ||
Macugen |
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Focus on Access (FOA) Program |
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Provided by: Bausch & Lomb Incorporated |
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PO Box 220662 TEL: 866-272-8838ALT PHONE: FAX: 866-272-8839 |
Languages Spoken:
English
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Patient Assistance Applications |
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Focus on Access (FOA) Program Enrollment Form |
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Focus on Access (FOA) Program Enrollment Form Instructions |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must have no prescription coverage or been denied coverage | ||
| Those with Part D Eligible? | Not specified | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Not required | ||
| US Residency Required? | Yes | ||
Application |
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| Obtaining | The Doctor should call for an application or download it from the website | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax or mail from Doctor's office | ||
| Doctor's Action | Complete section and sign | ||
| 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 Doctor notified in writing | ||
| Decision Timeframe | 3-5 business days | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Doctor's office or specific site | ||
| Delivery Time | Within 48 hours | ||
| Refill Process | Doctor's office must contact the company | ||
| Limit | None | ||
| Re-application | Once a year new application required. Financial documentation may be requested any time | ||
Additional Information |
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| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 2. | Updated January 08, 2015 | ||
Macugen |
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Patient Access Network Foundation (PAN)This is a copay assistance program. |
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Provided by: Patient Access Network Foundation |
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PO Box 221858 TEL: 866-316-7263ALT PHONE: FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Patient Assistance Applications |
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PAN Brochure |
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PAN Eligibility Criteria and Benefit Cap Information |
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PAN Proof of Expenditure Form |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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. As of 1/8/2015 Funds for Rheumatoid Arthritis, Psoriatic Arthritis, and Plaque Psoriasis have run out. |
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