Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 4.
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Procrit

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

This program provides medication at no cost.

Provided by: Johnson & Johnson Patient Assistance Foundation, Inc.

PO Box 220455
Charlotte, NC 28222-0455

TEL: 800-652-6227


FAX: 800-521-2437
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Johnson & Johnson Hospital Access Patient Assistance Program Application

 

Medications

  • Procrit (epoetin alfa)
  • Procrit|Vial (epoetin alfa)
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? Not specified
Income Based on FPL
Diagnosis/Medical Criteria Not applicable
US Residency Required? Must be residing in the US or US territory
   

Application

Obtaining Representative from the hospital must call for an application or download it from the website
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
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

This program allows eligible hospitals to receive free medications to give to qualified outpatients directly.

Contact the program for more details (1-800-652-6227).
Updated May 12, 2015


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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Procrit

Diplomat's Co-Pay Assistance Navigator Program

This is a copay assistance program.

Provided by: Diplomat Specialty Pharmacy

ATTN: FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507

TEL: 877-977-9118 ext. 89864


FAX: 810-282-0176
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Diplomat Request of Financial Assistance Form

 

Medications

  • Procrit (epoetin alfa)
  • Procrit|Vial (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/diagnosis
US Residency Required? Yes
   

Application

Obtaining Call or complete online
Receiving Faxed, mailed or complete online
Returning Fax or mail
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


Updated April 27, 2015


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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Procrit

Patient Access Network Foundation (PAN)

This is a copay assistance program.

Provided by: Patient Access Network Foundation

PO Box 221858
Charlotte, NC 28222-1858

TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

PAN Brochure

PAN Eligibility Criteria and Benefit Cap Information

PAN Proof of Expenditure Form

 

Medications

  • Procrit (epoetin alfa)
  • Procrit|Vial (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/diagnosis
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 and 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.

Updated June 03, 2015


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 4 of 4.
 

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

 

Program Applications and Forms

Johnson & Johnson Patient Assistance Foundation, Inc.-Patient Application

HIV Common Application; Johnson & Johnson (EDURANT, INTELENCE, PREZISTA)

 

Medications

  • Procrit (epoetin alfa)
  • Procrit|Vial (epoetin alfa)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? *See Additional Information Section Below
Income Varies. **See below for details
Diagnosis/Medical Criteria Not applicable
US Residency Required? Must reside permanently in the US or US territories
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and 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 Varies
Refill Process Varies per medication
Limit Varies
Re-application New application, new documentation yearly
   

Additional Information

*Some Medicare Part D patients who cannot afford their medicines, and who meet certain financial criteria, may also be eligible for assistance. Please Contact the program for more information (1-800-652-6227).

**Please call 1-800-652-6227 or visit Program website for specific FPL income requirements.

Updated May 11, 2015