Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Sebela Patient Assistance Program (Lotronex & Ridaura)

This program provides brand name medications at no or low cost

Provided by: Sebela Pharmaceuticals Inc.

PO Box 219
Gloucester, MA 01931

TEL: 866-562-7902


FAX: 888-246-6527
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Sebela Patient Assistance Program Application (Lotronex)

Sebela Patient Assistance Program Application (Ridaura)

 

Medications

  • alosetron (Lotronex) 
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case. *See Additional Information Section Below
Income At or below 300% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application

Obtaining Call or download
Receiving Faxed, emailed, mailed or downloaded
Returning Email, fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient notified by email or phone
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Contact the program for more details.
Sent To Doctor's office or patient's home
Delivery Time Once approved; shipped next business day
Refill Process Patient or Doctor's office needs to contact company
Limit None
Re-application New prescription every 3 months. New application every 6 months.
   

Additional Information

* Must not have Health insurance coverage (private or government) that pays for requested products and havenít for at least three months.

**Medicare Part D - Copy of insurance denial letter required.

***The manufacturer supporting this program does not charge for applying to the program nor for any products applicants receive. Applicants using the services of a commercial advocacy service may have to supply additional documentation.†
Updated July 24, 2017


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

HealthWell Foundation Copay Program

This is a copay assistance program

Provided by: HealthWell Foundation

PO Box 220410
Chantilly, VA 20153-0410

TEL: 800-675-8416


FAX: 800-282-7692
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

HealthWell Foundation Copay Program: Contact program

 

Medications

  • alosetron (Lotronex) 
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income Varies
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
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 and 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.
Updated May 22, 2017