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

Program 1 of 3   Scroll down to see them all.  Updated May 23, 2013 Back | Print Page

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

Macugen Access Program

Provided by:


Valeant Pharmaceuticals, Inc.
PO Box 220662
Charlotte, NC 28222-0662

TEL: 866-272-8838


ALT PHONE:
FAX: 866-272-8839
 Program Website

Languages Spoken: English

Patient assistance
applications

 

Medications

Macugen Injection 0.3mg (pegaptanib)

Eligibility Requirements

APPLICATION

MEDICATION
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
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, 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
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:

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

Program 2 of 3   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

Macugen   (pegaptanib)

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 3 of 3.  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

Macugen Injection 0.3mg (pegaptanib)

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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