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

CoverOne Program

This program provides brand name medications at no or low cost

Provided by: EMD Serono, Inc. and Pfizer, Inc.

Patient Enrollment Form
PO Box 29293
Phoenix, AZ 85038-9293

TEL: 844-826-8371


FAX: 800-214-7295
Languages Spoken:

English

Program Website

 

Program Applications and Forms

CoverOne Patient Enrollment Form

 

Medications

  • avelumab (Bavencio) 
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Yes
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Not specified
Sent To Doctor's office or specific site
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

This program also provides co-pay and reimbursement assistance.


Updated May 18, 2017