| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 4. Scroll down to see them all. |
|||
Macugen |
|||
Valeant Patient Assistance ProgramThis program provides brand name medications at no or low cost |
|||
Provided by: Valeant Pharmaceuticals, Inc. |
|||
PO Box 429303 TEL: 833-862-8727FAX: 866-777-5705 |
Languages Spoken:
English |
||
Program Applications and Forms |
|||
Valeant Patient Assistance Program Enrollment Form |
|||
Medications |
|||
|
|||
Eligibility Requirements |
|||
| Insurance Status | Must have no prescription coverage for needed medication | ||
| Those with Part D Eligible? | Determined case by case | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Medication must be for outpatient use only | ||
| US Residency Required? | Must be a US resident and treated by a US licensed healthcare provider | ||
Application |
|||
| Obtaining | Call or download | ||
| Receiving | Faxed or downloaded from website | ||
| 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 | 2 business days, once application process is complete | ||
Medication |
|||
| Amount/Supply | Varies | ||
| Sent To | Varies | ||
| Delivery Time | Not specified | ||
| Refill Process | Not specified | ||
| Limit | One year | ||
| Re-application | New application yearly | ||
Additional Information |
|||
| Hardship appeals for patients residing in Puerto Rico will be reviewed on a case-by-case basis. Call for information on the most recent medications as the list is subject to change. |
|||
| Updated April 05, 2018 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 4. Scroll down to see them all. |
|||
Macugen |
|||
Good Days ProgramThis is a copay assistance program |
|||
Provided by: Good Days from CDF |
|||
Attn: Enrollment TEL: 877-968-7233FAX: 214-570-3621 |
Languages Spoken:
English |
||
Program Applications and Forms |
|||
Good Days Program Patient Enrollment Application (pages: 3-5) |
|||
Good Days Program Enrollment Information Pages (pages: 1 & 2) |
|||
Medications |
|||
|
|||
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 February 26, 2018 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 4. Scroll down to see them all. |
|||
Macugen |
|||
HealthWell Foundation Copay ProgramThis is a copay assistance program |
|||
Provided by: HealthWell Foundation |
|||
PO Box 220410 TEL: 800-675-8416FAX: 800-282-7692 |
Languages Spoken:
English, Others By Translation Service |
||
Program Applications and Forms |
|||
HealthWell Foundation Copay Program: Contact program |
|||
Medications |
|||
|
|||
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 | |||
| 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 January 03, 2018 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 4 of 4. | |||
Macugen |
|||
Patient Access Network Foundation (PAN)This is a copay assistance program |
|||
Provided by: Patient Access Network Foundation |
|||
PO Box 221858 TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
||
Program Applications and Forms |
|||
Patient Access Network Foundation (PAN) Application: Contact program |
|||
Medications |
|||
|
|||
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 May 24, 2018 | |||
