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 April 16, 2014
Pegasys

Genentech Access to Care Foundation (Pegasys)

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

Provided by: Genentech, Inc.

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

TEL: 888-941-3331


ALT PHONE:
FAX: 888-929-3334
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website
 

Patient Assistance Applications

Genentech Patient Auth. and Notice of Release of Information (PAN); Pegasys

Genentech Patient Auth. and Notice of Release of Information (PAN); Pegasys (Spanish)

Genentech Statement of Medical Necessity; Pegasys

Genentech Insurance Attestation Form; Pegasys

Genentech Financial Attestation Form; Pegasys

 

Medications

  • Pegasys Injection 180mcg (peginterferon alfa-2a)
 

Eligibility Requirements

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
   

Application

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
   

Medication

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.
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Updated April 11, 2014
Pegasys

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

  • Pegasys Injection 180mcg (peginterferon alfa-2a)
 

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 3 of 5.
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Updated March 04, 2014
Pegasys

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

  • Pegasys Injection 180mcg (peginterferon alfa-2a)
 

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 4 of 5.
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Updated January 30, 2014
Pegasys

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

  • Pegasys Injection 180mcg (peginterferon alfa-2a)
 

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.



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

Program 5 of 5. Updated January 20, 2014
Pegasys

Pegasys Co-Pay Card Program

This is a copay assistance 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
Languages Spoken:

English, Others By Translation Service

Program Website
 

Patient Assistance Applications

Pegasys Co-Pay Card Program Patient Authorization Form

Pegasys Co-Pay Card Program Patient Authorization Form (Spanish)

Pegasys Co-Pay Card Program Statement of Medical Necessity

 

Medications

  • Pegasys Injection 180mcg (peginterferon alfa-2a)
 

Eligibility Requirements

Insurance Status Must have insurance, must not have public 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
   

Application

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
   

Medication

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.