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Rituxan

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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

  • Rituxan (rituximab)
 

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 July 10, 2015


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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

  • Rituxan injection (rituximab)
 

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 July 27, 2015


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Rituxan

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Genentech Access to Care Foundation (Avastin, Herceptin, Rituxan)

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

Provided by: Genentech, Inc.

PO Box 2807
South San Francisco, CA 94083-2807

TEL: 888-249-4918


FAX: 888-249-4919
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Genentech Patient Auth. and Notice of Release of Information (PAN);Avastin, Herceptin, Rituxan

Genentech Patient Auth.and Notice of Release of Information(PAN);Avastin, Herceptin, Rituxan-Spanish

Genentech Statement of Medical Necessity; Avastin, Herceptin, Rituxan

Genentech Insurance Attestation-HCP Form; Avastin

Genentech Insurance Attestation-HCP Form; Herceptin

Genentech Insurance Attestation-HCP Form; Rituxan

Genentech Patient Financial Attestation Form; Avastin, Herceptin, Rituxan

Genentech Confirmation of Infusion or Injection Form; Avastin

Genentech Confirmation of Infusion or Injection Form; Herceptin

Genentech Confirmation of Infusion or Injection Form; Rituxan

Genentech Fax Cover Sheet; Avastin

Genentech Fax Cover Sheet; Herceptin

Genentech Fax Cover Sheet; Rituxan

 

Medications

  • Rituxan injection (nhl & cll) (rituximab)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? Determined case by case
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 Fax or mail
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 Doctor's office, hospital, or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information

Rituxan NHL: Non-Hodgkins Lymphoma

Rituxan CLL: Chronic Lymphocytic Leukemia
Updated May 01, 2015


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Rituxan

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Genentech Access to Care Foundation (Actemra, Rituxan)

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

Provided by: Genentech, Inc.

1 DNA Way, Mail Stop 857A
South San Francisco, CA 94080

TEL: 866-681-3329


FAX: 866-681-3338
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Genentech Patient Auth. and Notice of Release of Information (PAN); Actemra & Rituxan

Genentech Patient Auth. and Notice of Release of Information (PAN); Actemra & Rituxan (Spanish)

Genentech Statement of Medical Necessity; Actemra & Rituxan

Genentech Insurance Attestation-Patients Form; Actemra

Genentech Insurance Attestation-HCP Form; Actemra

Genentech Insurance Attestation-HCP Form; Rituxin

Genentech Patient Financial Attestation Form; Actemra, Rituxan

Genentech Confirmation of Infusion or Injection Form; Actemra

Genentech Confirmation of Infusion or Injection Form; Rituxan

Genentech Benefits Reverification Enrollment Form

 

Medications

  • Rituxan injection (ra, gpa & mpa) (rituximab)
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage or been denied coverage
Those with Part D Eligible? Determined case by case
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 enrollment/statement of medical necessity forms
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
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 Doctor's office, hospital, or pharmacy
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application New application yearly
   

Additional Information

Rituxan RA: Rheumatoid Arthritis

Rituxan MPA: Microscopic Polyangilitis

Rituxan GPA: Granulomatosis with Polyangilits (Formerly known as Wegener’s Granulomatosis)

Updated May 01, 2015