Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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Updated October 17, 2014
 

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


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

 

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.


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
Scroll down to see them all.
Updated September 25, 2014
 

Step Up, Start Up Copay Assistance Program

This is a copay assistance program.

Provided by: Antares Pharma


TEL: 855-202-5711


ALT PHONE: 855-687-3987
FAX: 646-419-4065
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

 Step Up, Start Up Copay Assistance Program Card: Contact Program

Step Up, Start Up Otrexup Injector Disposal Kit Request Form

Step Up, Start Up Mail-In Rebate Form

 

Medications

  • methotrexate Injection 10mg/0.4mL, 15mg/0.4mL, 20mg/0.4mL, 25mg/0.4mL (Otrexup)
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not Required
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be a US resident
   

Application

Obtaining No application
Receiving There is no application
Returning Not applicable
Doctor's Action Give prescription to patient
Applicant's Action Print copay card from program website, bring to pharmacy with prescription to receive savings
Decision Communicated Not applicable
Decision Timeframe Not applicable
   

Medication

Amount/Supply Not applicable
Sent To Not applicable
Delivery Time Not applicable
Refill Process Good for one year
Limit Maximum of 12 times in one year
Re-application Request a new card after one year
   

Additional Information

Eligible patients may save up to $125 on each prescription

Otrexup Injector Disposal Program: Complete Request Form and Fax


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3. Updated December 11, 2014
 

Rx Outreach Medications

This program provides medication at low cost.

Provided by: Rx Outreach

PO Box 66536
St Louis, MO 63166-6536

TEL: 888-796-1234


ALT PHONE:
FAX: 800-875-6591
Languages Spoken:

English, Spanish

Program Website

 

Patient Assistance Applications

Rx Outreach Application

Rx Outreach Diabetic Supplies

Rx Outreach Refills and New Prescriptions Order Form

Rx Outreach Medication List

 

Medications

  • methotrexate Tablet 2.5mg ()
 

Eligibility Requirements   

Insurance Status May have insurance
Those with Part D Eligible? Yes
Income At or below 300% of FPL
Diagnosis/Medical Criteria Not required
US Residency Required? Must reside in the US
   

Application

Obtaining Call, download or apply online
Receiving Faxed or mailed
Returning Fax or E-Prescribe online
Doctor's Action Give prescription to patient
Applicant's Action Complete section and sign
Decision Communicated Medications sent if accepted. If denied patient and doctor notified
Decision Timeframe Usually same day
   

Medication

Amount/Supply Varies
Sent To Doctor's office or patient's home
Delivery Time Not specified
Refill Process Company contacts patient to arrange
Limit Only limited by manufacturer's guidelines
Re-application New application yearly
   

Additional Information

Some medications are available for a fee of $20 for up to a 180 day supply.
Check the Rx Outreach website for the exact price and most current medication list.
Contact Program for Spanish Application(s)/Form(s)