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

Program 1 of 5.
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Updated February 14, 2014
Neulasta

The Safety Net Foundation

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

Provided by: Amgen, Inc.

PO Box 18769
Louisville, KY 40261-7821

TEL: 888-762-6436


ALT PHONE:
FAX: 866-549-7239
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

 The Safety Net Foundation: Contact program

 

Medications

  • Neulasta Injection 6mg/0.6mL (pegfilgrastim)
 

Eligibility Requirements

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? No
Income Income Guidelines published on Program Website
Diagnosis/Medical Criteria Not applicable
US Residency Required? Must reside permanently in the US , Guam, Puerto Rico or U.S. Virgin Islands
   

Application

Obtaining Call or download
Receiving Mailed or downloaded from website
Returning Fax or mail from Doctor's office
Doctor's Action Complete section, sign, attach prescription
Applicant's Action Complete section, sign
Decision Communicated Doctor notified
Decision Timeframe 2-5 business days
   

Medication

Amount/Supply Varies
Sent To Address of shipment varies by medication
Delivery Time Not specified
Refill Process Determined on a case by case basis
Limit Not specified
Re-application New application every 12 months
   

Additional Information

Please visit www.SafetyNetFoundation.com for more information



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

Program 2 of 5.
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Updated March 18, 2014
Neulasta

Amgen FIRST STEP Co-Pay Support

This is a copay assistance program.

Provided by: Amgen, Inc.


TEL: 888-657-8371


ALT PHONE:
FAX: 888-653-2972
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

 Amgen FIRST STEP Co-Pay Support: Contact program

 

Medications

  • Neulasta Injection 6mg/0.6mL (pegfilgrastim)
 

Eligibility Requirements

Insurance Status Must have insurance
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition
US Residency Required? Must be citizen
   

Application

Obtaining Applicant must call for prescreening
Receiving Not applicable
Returning Not applicable
Doctor's Action Enroll in program, complete form and obtain patient consent
Applicant's Action Call to enroll
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not applicable
Sent To Card sent to doctor's office or to patient's home
Delivery Time Not specified
Refill Process Doctor/doctor's office must contact the Program
Limit None
Re-application Card is valid for the enrolled patientís entire course of treatment.
   

Additional Information

Health Care Providers must enroll in the program prior to processing the Amgen FIRST STEP Program Cards

The card is valid for the patient's entire course of treatment. Eligible patients may re-enroll at any time a new course of treatment is initiated.



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

Program 3 of 5.
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Updated April 11, 2014
Neulasta

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

  • Neulasta Syringe 6mg/6mL (pegfilgrastim)
 

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.



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

Program 4 of 5.
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Updated March 04, 2014
Neulasta

HealthWell Foundation Copay Program

This is a copay assistance program.

Provided by: HealthWell Foundation

P.O Box 4133
Gaithersburg, MD 20897-7811

TEL: 800-675-8416


ALT PHONE:
FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

Reimbursement Request Form - Copayment Assistance

 

Medications

  • Neulasta  dosage varies (pegfilgrastim)
 

Eligibility Requirements

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
   

Application

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 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.



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

Program 5 of 5. Updated April 21, 2014
Neulasta

Patient Access Network Foundation

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


ALT PHONE:
FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Neulasta Syringe dosage varies (pegfilgrastim)
 

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
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, 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.