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

Program 1 of 5   Scroll down to see them all.  Updated June 18, 2013 Back | Print Page

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

Genentech Access to Care Foundation (Pegasys)

Provided by:


Genentech, Inc.
P.O. Box 2807
South San Francisco, CA 94083-2807

TEL: 888-941-3331


ALT PHONE:
FAX: 888-929-3334
 Program Website

Languages Spoken: English, Spanish, Others By Translation Service

Patient assistance
applications

 

Medications

Pegasys Injection 180mcg (peginterferon alfa-2a)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? No
Income Gross annual household income at or below $100,000
Diagnosis/Medical Criteria Not disclosed
US Residency Required? Must be treated by US licensed healthcare provider
Obtaining Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete and sign statement of medical necessity
Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
Decision Communicated Not specified
Decision Timeframe Not specified
Amount/Supply Varies
Sent To Patient's home, doctor's office, hospital or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly

Additional Information:

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

Program 2 of 5   Scroll down to see them all.  Updated March 25, 2013 Back | Print Page

This is a copay assistance program.

Diplomat's Co-Pay Assistance Navigator 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
 Program Website

Languages Spoken: English

Patient assistance
applications


 

Medications

Pegasys Injection 180mcg (peginterferon alfa-2a)

Eligibility Requirements

APPLICATION

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

Program 3 of 5   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

Pegasys Injection 180mcg (peginterferon alfa-2a)

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 4 of 5   Scroll down to see them all.  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

Pegasys Injection 180mcg (peginterferon alfa-2a)

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

Program 5 of 5.  Updated May 29, 2013 Back | Print Page

This is a copay assistance program.

Pegasys Co-Pay Card Program

Provided by:


Genentech, Inc.
1 DNA Way, MS-858A
South San Francisco, CA 94080

TEL: 888-202-9939


ALT PHONE:
FAX: 888-929-3334
 Program Website

Languages Spoken: English, Others By Translation Service

Patient assistance
applications


 

Medications

Pegasys Injection 180mcg (peginterferon alfa-2a)

Eligibility Requirements

APPLICATION

MEDICATION
Insurance Status Must not have public insurance, may have private insurance
Those with Part D Eligible? No
Income No limits
Diagnosis/Medical Criteria Chronic Hepatitis B or C
US Residency Required? VT residents are not eligible
Obtaining Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete and sign statement of medical necessity
Applicant's Action Complete Patient Authorization and Notice of Information Form available on website, attach proof of income
Decision Communicated Patient notified
Decision Timeframe Not specified
Amount/Supply Not applicable
Sent To Patient sent card to be used at pharmacy
Delivery Time Shipped next business day
Refill Process Patient presents voucher/card to pharmacy for each refill
Limit None
Re-application New application yearly

Additional Information:

There are two plans, one will cover $125 per month with an annual limit of $1500, the other will cover $200 per month with an annual limit of $2400.



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