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Program 1 of 4.
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Updated February 21, 2014
Procrit

Johnson & Johnson Patient Assistance Foundation Hospital Access Patient Assistance Program

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

Provided by: Johnson & Johnson Patient Assistance, Inc

PO Box 220455
Charlotte, NC 28222-0455

TEL: 800-652-6227


ALT PHONE:
FAX: 800-521-2437
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

Johnson & Johnson Hospital Access Patient Assistance Program

 

Medications

  • Procrit Vial dosage varies (epoetin alfa)
 

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 Someone from the hospital must call for an application or download it from the website.
Receiving Pre-filled application will be sent to Doctor's office
Returning Mail or fax
Doctor's Action Hospital must complete product request form for each replacement
Applicant's Action Not specified
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Hospital
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Patients receiving Procrit for dialysis are not eligible for this program. This program is intended to provide qualified outpatients access to medications through a qualified DSH or DRG-exempt Cancer Center. DSH facilities and DRG-exempt Cancer Centers are assessed for eligibility according to standardized criteria.

TRAMADOL NOT AVAILABLE IN THE HAPAP PROGRAM IN STATES WHERE IT HAS BEEN CLASSIFIED AS A CONTROLLED/SCHEDULED II

Contact program for Spanish application.



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

Program 2 of 4.
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Updated January 24, 2014
Procrit

Johnson & Johnson Patient Assistance Foundation, Inc. Patient Assistance Program

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

Provided by: Johnson & Johnson Patient Assistance Foundation, Inc

PO Box 221857
Charlotte, NC 28222-1857

TEL: 800-652-6227


ALT PHONE: 800-523-5870
FAX: 888-526-5168
Languages Spoken:

English

Program Website
 

Patient Assistance Applications

HIV Common Application; Johnson & Johnson

Johnson & Johnson Patient Assistance Foundation, Inc. Application

 

Medications

  • Procrit Injection dosage varies (epoetin alfa)
 

Eligibility Requirements

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Not specified
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Mail or fax
Doctor's Action Complete section, sign
Applicant's Action Complete section, sign, attach a copy of proof of income
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Doctor's office or patient is sent card to be used at pharmacy
Delivery Time Not specified
Refill Process Automatically sent out
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information

Medicare LIS (Low Income Subsidy) eligible patients are not eligible to receive assistance through this program.

This Program participates in the CPAPA. This single common application allows uninsured HIV-positive individuals with low incomes to use one application to apply for multiple assistance programs.

IMPORTANT: Send completed CPAPA to the corresponding addresses listed for each company.

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 4.
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Updated April 11, 2014
Procrit

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

  • Procrit Solution for Injection 2000 units/mL, 3000 units/mL, 10000units/mL, 20000 units/mL, 40000 units/mL (epoetin alfa)
 

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 4. Updated January 30, 2014
Procrit

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

  • Procrit Vial dosage varies (epoetin alfa)
 

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.