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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

 

Patient Assistance Applications

Patient Access Network Foundation (PAN) Application: Contact program

 

Brand Name Medications Covered

 
  • 8-MOP
  • Lioresal
  • A-Hydrocort
  • Lipitor
  • A-Methapred
  • Lipofen capsule
  • Abraxane
  • Liptruzet tablet
  • Absorica capsule
  • Livalo tablet
  • Accolate
  • Locoid lotion
  • Accuneb
  • Lodine
  • Accupril
  • Lodosyn tablet
  • Accuretic
  • Lofibra (Micronized)
  • Aceon
  • Lonsurf
  • Aclovate
  • Lopid
  • Actemra
  • Lopressor
  • Acthrel
  • Lopressor HCT tablet
  • Actimmune
  • Lotensin
  • Actonel tablet
  • Lucentis
  • Adcetris
  • Lufyllin
  • Adriamycin
  • Lupron Depot
  • Adrucil
  • Luxiq
  • Advair Diskus
  • Lynparza
  • Advair HFA
  • Lysodren
  • Advicor tablet; extended release
  • Macugen
  • Aerospan HFA
  • Marinol
  • Afinitor
  • Marqibo Kit
  • Afinitor Disperz tablet
  • MatriStem Burn Matrix tissue matrix; extracellular
  • Agrylin
  • MatriStem MicroMatrix tissue matrix; extracellular
  • Akynzeo capsule
  • MatriStem Wound Matrix tissue matrix; extracellular
  • Aldactazide tablet
  • Matulane
  • Aldactone
  • Matzim
  • Aldara
  • Mavik
  • Alecensa
  • Maxitrol ophthalmic ointment
  • Alimta
  • Maxzide
  • Alkeran
  • Medrol
  • AlloDerm
  • Megace
  • AlloSkin
  • Megace ES
  • AlloWrap
  • Mekinist
  • Alora
  • Menest
  • Aloxi injection
  • Menostar
  • Altace
  • Mephyton
  • Altoprev tablet; extended release
  • Mesnex
  • Alunbrig
  • Metastron
  • Alvesco
  • Metopirone
  • Amidate
  • Metozolv tablet; orally disintegrating
  • Amnesteem
  • Mevacor tablet
  • Amnioband
  • Miacalcin
  • AmnioExcel
  • Micardis
  • AmnioMatrix
  • Micardis HCT tablet
  • Ampyra
  • MiCort HC
  • Anaprox
  • Microzide
  • Anaprox DS
  • Mifeprex
  • Androxy
  • Millipred
  • Antara capsule
  • Minivelle transdermal system
  • Anzemet
  • Mirapex
  • Apexicon
  • Mirapex ER
  • ApexiCon E
  • Mobic
  • Apligraf
  • Moderiba
  • Apokyn
  • Mozobil
  • Apriso
  • Multaq tablet
  • Aptivus
  • Mustargen
  • AquaSol A
  • Myleran
  • Aranesp
  • Myorisan
  • Arava
  • Nalfon
  • Arimidex
  • Naprelan
  • Arnuity Ellipta powder; inhalation
  • Naprosyn
  • Aromasin
  • Navelbine
  • Arranon injection
  • Neo-Polycin
  • ArthroFlex
  • Neo-Synalar
  • Arthrotec
  • Neoral
  • Arzerra
  • Neosporin
  • Asacol HD
  • Neulasta
  • Asmanex
  • Neupogen
  • Asmanex HFA
  • Neupro
  • Astagraf XL
  • Nexavar
  • Atacand
  • Nexterone
  • Atacand HCT
  • Niacor tablet
  • Atelvia tablet; delayed release
  • Niaspan
  • Atgam
  • Nilandron
  • Ativan
  • Ninlaro
  • Atripla
  • Nipent
  • Atrovent HFA
  • Niravam
  • Aubagio
  • Norditropin FlexPro
  • Auryxia
  • Norditropin NordiFlex
  • Avalide
  • Norpace capsule
  • Avapro
  • Norpace CR capsule; extended release
  • Avastin
  • Norvir
  • Avonex
  • Nplate
  • Azasan
  • Nucala
  • Azilect
  • Nucort
  • Azulfidine
  • Nuplazid tablet
  • Beleodaq
  • Nutrestore
  • Bendeka
  • Nutropin
  • Benicar
  • Nutropin AQ
  • Benicar HCT
  • Nutropin AQ NuSpin
  • Betapace
  • Oasis
  • Betaseron
  • Ocrevus
  • Bicnu
  • Octagam
  • BiDil tablet
  • Odefsey
  • Binosto
  • Odomzo capsule
  • BioDFence
  • Ofev
  • BioDFence DryFlex
  • Olux foam
  • BioVance
  • Olux-E foam
  • Bivigam liquid
  • Olysio
  • Blephamide
  • Omnipred
  • Blephamide S.O.P.
  • Omnitrope
  • Blincyto injection
  • Oncaspar vial
  • Boniva
  • Opdivo
  • Bosulif
  • Orapred
  • Breo Ellipta
  • Orencia
  • Brevibloc
  • Otezla
  • Busulfex
  • Otrexup
  • Bystolic tablet
  • Oxsoralen
  • Cabometyx
  • Ozurdex
  • Caduet
  • Pacerone tablet
  • Calan
  • Pancreaze
  • Calcitrene
  • Pandel
  • Cambia oral solution
  • Parlodel
  • Campath
  • Pediaderm HC
  • Camptosar
  • Pediaderm TA
  • Canasa
  • Pediapred
  • Capex
  • Pegasys
  • Caprelsa
  • Pegasys ProClick auto-injector
  • Carac
  • Pennsaid
  • Cardizem
  • Pentasa
  • Cardizem LA tablet; extended release
  • Perforomist
  • Carimune NF injection
  • Perjeta
  • Cartia XT
  • Pertzye
  • Casodex
  • Phenergan
  • Cataflam
  • Phoslo
  • CeeNU
  • Phoslyra oral solution
  • Celebrex
  • Photofrin
  • Celestone
  • Plaquenil
  • Cellcept
  • Plegridy
  • Cenestin tablet
  • Pomalyst
  • Cerdelga
  • Portrazza
  • Cerezyme
  • Praluent
  • Cerubidine
  • Pravachol
  • Cesamet capsule
  • Pred Forte
  • Chemet
  • Pred Mild
  • Cimzia
  • Pred-G
  • Cinqair
  • Prelone
  • Claravis
  • Premarin
  • ClarixFlo
  • Prevalite
  • Climara
  • Prezcobix
  • Clobex lotion; shampoo; spray
  • Prezista
  • Clodan
  • Prinivil
  • Cloderm cream
  • Privigen vial; single-use
  • Clolar
  • Proair HFA
  • Cogentin
  • Proair Respiclick
  • Colazal
  • Procrit
  • Colestid
  • Proglycem
  • Combivent Respimat
  • Prograf
  • Combivir
  • Proleukin
  • Cometriq
  • Prolia
  • Compazine
  • Promacta
  • Complera
  • Promethegan
  • Compro
  • Promogran
  • Comtan
  • Protopic
  • Copaxone
  • Provenge
  • Copegus
  • Proventil HFA
  • Cordarone
  • Psorcon
  • Cordran
  • Pulmicort
  • Coreg
  • Pulmicort Flexhaler
  • Coreg CR
  • Qbrelis
  • Corgard tablet
  • Quadramet
  • Corlanor tablet
  • Questran
  • Cormax
  • QVAR
  • Cortef
  • Rapamune
  • Cortisporin
  • Rasuvo
  • Cortone
  • Rayaldee
  • Corvert injection
  • Rayos
  • Corzide
  • Rebetol
  • Cosentyx
  • Rebif
  • Cotellic
  • Reclast
  • Cozaar
  • Reglan
  • Creon
  • Regranex
  • Crestor
  • Remicade
  • Crixivan
  • Renagel
  • Cuprimine
  • Renvela
  • Cutivate
  • Repatha
  • Cyclogyl
  • Repatha Sureclick auto-injector; pre-filled
  • Cymetra
  • Replesta
  • Cyramza
  • Requip
  • Dacogen
  • Rescriptor
  • Daklinza
  • Retisert
  • Darzalex
  • Retrovir
  • Daypro
  • Revlimid
  • Delestrogen
  • Reyataz
  • Deltasone
  • Rheumatrex
  • Delzicol
  • Rhophylac
  • Demadex
  • Ribasphere
  • Depen
  • Ribasphere RibaPak
  • Depo-Estradiol
  • Ribatab
  • Depo-Medrol
  • Ridaura
  • DepoCyt
  • Rituxan
  • Derma-Smoothe
  • Rocaltrol
  • DermaCell
  • Rowasa
  • Dermagraft
  • Rubraca
  • DermaPure
  • Rydapt
  • Dermasorb TA
  • Rytary capsule; extended release
  • Dermatop
  • Rythmol
  • DermaVest
  • Sabril
  • DermOtic Oil Ear Drop oil ear drops; otic
  • Saizen
  • Descovy
  • Sancuso transdermal patch
  • Desferal
  • Sandimmune
  • Desonate gel
  • Sandostatin
  • DesOwen cream
  • Sandostatin LAR
  • DexPak
  • Scalacort
  • Digox
  • Sectral
  • Dilacor XR
  • Selzentry
  • Dilatrate SR
  • Sensipar
  • Dilt-CD
  • Serevent
  • Dilt-XR capsule; extended release
  • Sernivo
  • Diltzac
  • Serostim injection
  • Diovan
  • Sfrowasa
  • Diovan HCT
  • Signifor
  • Dipentum
  • Signifor LAR
  • Diphen
  • Siliq
  • Diprolene
  • Silphen
  • Diuril injection
  • Simcor tablet; extended release
  • Diuril suspension
  • Simponi
  • Divigel gel
  • Simponi Aria
  • Docefrez
  • Sinemet
  • Dovonex
  • Sinemet CR
  • Doxil
  • Singulair
  • Drisdol
  • Solodyn
  • Droxia
  • Soltamox
  • Duavee
  • Solu-Cortef
  • Duexis
  • Solu-Medrol
  • Dulera
  • Somatuline Depot
  • DuoNeb
  • Somavert
  • Duopa
  • Soriatane
  • Dupixent
  • Sorilux aerosol; foam
  • Durezol
  • Sorine tablet
  • Dutoprol tablet; extended release
  • Sotylize oral solution
  • Dyazide
  • Sovaldi
  • Dyrenium capsule
  • Spiriva HandiHaler powder; inhalation
  • Ec-Naprosyn
  • Spiriva Respimat spray
  • Edarbi tablet
  • Sprycel
  • Edarbyclor tablet
  • Sps
  • Edurant
  • Stalevo
  • Efudex
  • Stelara
  • Eldepryl
  • Stiolto Respimat spray
  • Elelyso
  • Stivarga
  • Elestrin gel
  • Stribild
  • Elidel
  • Sustiva
  • Eligard
  • Sustol
  • Eliphos
  • Sutent
  • Elixophyllin
  • Sylatron
  • Ellence
  • Symbicort
  • Elocon
  • Synagis
  • Eloxatin
  • Synalar
  • Emend capsule
  • Synribo
  • Emend injection
  • Synthroid
  • Empliciti
  • Syprine
  • Emtriva
  • Taclonex suspension; topical
  • Enbrel
  • Tafinlar
  • Enjuvia tablet
  • Tagrisso
  • Enstilar
  • Taltz
  • Entocort EC
  • Talymed
  • Entresto tablet
  • Tambocor
  • Entyvio
  • Tarceva
  • Envarsus XR
  • Targretin gel; capsule
  • Epaned oral solution
  • Tasigna
  • Epclusa
  • Tasmar tablet
  • EpiFix
  • Taxotere
  • Epivir
  • Tazorac
  • Epivir-HBV
  • Taztia
  • Epogen
  • Tecentriq
  • Epzicom
  • Tecfidera
  • Erbitux
  • Technivie tablet
  • Erivedge
  • Temodar
  • Erwinaze injection
  • Temovate
  • Esbriet
  • Tenoretic
  • Estrace
  • Tenormin
  • Estraderm film; transdermal system
  • Teveten
  • Estrasorb emulsion; topical
  • Teveten HCT tablet
  • EstroGel gel
  • Texacort
  • Etopophos
  • Thalomid
  • Eucrisa
  • Theo-24
  • Evamist spray
  • Theochron
  • Evista
  • TheraCys
  • Evomela
  • TheraSkin
  • Evotaz
  • Thyrogen
  • Excellagen
  • Tiazac
  • Exelon
  • TICE BCG
  • Exjade
  • Tikosyn
  • Extavia
  • Tirosint
  • Eylea
  • Tivicay
  • EZ Derm
  • Tivorbex capsule
  • Fareston
  • Tobradex ST
  • Farydak
  • Topicort
  • Faslodex
  • Toposar
  • Feldene
  • Toprol XL
  • Femara
  • Torisel
  • Fenoglide tablet
  • Trandate tablet
  • Ferriprox
  • Treanda
  • Fibricor tablet
  • Trelstar
  • Firmagon
  • Trexall
  • Flarex ophthalmic suspension/drops
  • Tri-Luma
  • Flebogamma DIF
  • Trianex
  • Flector Patch patch
  • Tricor
  • FlexHD
  • Triderm
  • Flo-Pred
  • Tridesilon
  • Flonase
  • Triesence
  • Flovent Diskus
  • Triglide tablet
  • Flovent HFA
  • Trilipix
  • Fluoroplex
  • Triumeq
  • FML
  • Trizivir
  • FML-Forte
  • Truvada
  • Folotyn
  • Tybost
  • Foradil Aerolizer
  • Tykerb
  • Fortaderm
  • Tymlos
  • Fortaderm Antimicrobial
  • Tysabri
  • Forteo
  • U-Cort
  • Fortical
  • Uceris
  • Fosamax
  • Ultravate
  • Fosamax Plus D
  • Ultresa
  • Fosrenol
  • Uniretic
  • Fusilev
  • Unite Biomatrix
  • Fuzeon
  • Unithroid
  • Gablofen
  • Univasc
  • Galzin
  • Valchlor
  • Gammagard Liquid
  • Vanos cream; 0.1%
  • GammaGraft
  • Vantas implant
  • Gammaked
  • Varubi tablet
  • Gammaplex iv
  • Vaseretic
  • Gamunex
  • Vasotec
  • Gamunex-C
  • Vectibix
  • Gattex
  • Vectical
  • Gazyva
  • Velcade
  • Gemzar
  • Velphoro
  • Gengraf
  • Veltassa
  • Genotropin
  • Venclexta
  • Genvoya
  • Ventolin HFA
  • Giazo tablet
  • Verdeso
  • Gilenya
  • Verelan
  • Gilotrif
  • Veripred
  • Glatopa
  • Vexol ophthalmic suspension/drops
  • Gleevec
  • Vidaza
  • Gleostine
  • Videx
  • Grafix CORE
  • Viekira Pak
  • Grafix PRIME
  • Vimovo
  • Graftjacket
  • Vincasar PFS
  • Graftjacket Xpress
  • Viokace
  • Granisol oral solution
  • Viracept
  • Granix
  • Viramune
  • H.P. Acthar Gel
  • Viramune XR
  • Halaven
  • Viread
  • Haldol
  • Vistaril
  • Halog
  • Visudyne
  • Harvoni
  • Vitekta tablet
  • Hecoria
  • Vivelle-Dot
  • Hectorol
  • Voltaren
  • Helicoll
  • Voltaren XR
  • Hemangeol
  • Vospire ER
  • Herceptin
  • Votrient
  • Hexalen
  • VPRIV
  • Humatrope
  • Vytorin tablet
  • Humira
  • Welchol
  • Hyalomatrix
  • Westcort
  • Hycamtin
  • WinRho SDF
  • Hydrea
  • Xadago
  • Hyzaar
  • Xalkori
  • Ibrance
  • Xanax
  • Iclusig
  • Xatmep
  • Ifex
  • Xeljanz
  • Iluvien implant
  • Xeloda
  • Imbruvica
  • Xerese cream; topical
  • Imlygic
  • Xgeva
  • Imuran
  • Xifaxan
  • Inderal LA
  • Xofigo
  • Indocin
  • Xolair
  • Infergen
  • Xopenex
  • Inflectra
  • Xopenex HFA
  • Inlyta
  • Xtandi
  • InnoPran XL capsule; extended release
  • Yervoy
  • Inspra tablet
  • Zaltrap
  • Integra
  • Zanaflex
  • Integra DRT
  • Zanosar
  • Integra Flowable
  • Zaroxolyn
  • Intelence
  • Zarxio injection
  • Intron A
  • Zavesca
  • Invirase
  • Zebeta tablet
  • Iressa
  • Zejula
  • Isentress
  • Zelapar tablet; orally disintegrating
  • Isopto Atropine
  • Zelboraf
  • Isordil
  • Zemplar
  • Istodax
  • Zenatane
  • Ixempra
  • Zenpep
  • Jadenu
  • Zepatier
  • Jakafi
  • Zerit
  • Jetrea
  • Zestoretic
  • Jevtana
  • Zestril
  • Juxtapid
  • Zetia tablet
  • Kadcyla
  • Zevalin
  • Kaletra
  • Ziac
  • Kayexalate powder
  • Ziagen
  • Kenalog
  • Zinbryta
  • Kevzara
  • Zipsor
  • Keytruda
  • Zithranol Shampoo shampoo
  • Kineret injection
  • Zithranol-RR encapsulated cream
  • Kionex
  • Zocor
  • Kisqali
  • Zofran
  • Kisqali Femara tablet; co-pack
  • Zoladex
  • Korlym
  • Zolinza
  • Kynamro
  • Zomacton
  • Kyprolis
  • Zometa
  • Lanoxin tablet
  • Zorbtive
  • Lasix
  • Zortress
  • Lemtrada
  • Zorvolex capsule
  • Lenvima
  • Zuplenz
  • Lescol capsule
  • Zydelig
  • Leukeran
  • Zyflo
  • Leukine
  • Zyflo CR
  • Levo-T
  • Zykadia
  • Levoxyl
  • Zylet ophthalmic suspension/drops
  • Levulan Kerastick
  • Zyprexa
  • Lexiva
  • Zyprexa Zydis
  • Lialda
  • Zytiga
 

Generic Name

 
  • abacavir sulfate
  • imiglucerase
  • abacavir sulfate/dolutegravir sodium/lamivudine
  • imiquimod
  • abacavir sulfate/lamivudine
  • immune globulin
  • abacavir sulfate/lamivudine/zidovudine
  • immune globulin-rhoD Intravenous (human)
  • abaloparatide
  • immune globulin; intravenous
  • abatacept
  • immune globulin; intravenous (human)
  • abiraterone acetate
  • immune globulin; intravenous (human) injection
  • acebutolol
  • immune globulin; intravenous (human) liquid
  • acellular dermal allograft
  • immune globulin; intravenous (human) vial; single-use
  • acitretin
  • immune globulin; intravenous iv
  • acyclovir hydrocortisone cream; topical
  • immune globulin; iv (human)
  • adalimumab
  • immune globulin; lymphocyte
  • ado-trastuzumab emtansine
  • immune globulin; rh
  • afatinib
  • indinavir sulfate
  • aflibercept
  • indomethacin
  • albuterol
  • indomethacin capsule
  • albuterol sulfate
  • infliximab
  • albuterol sulfate/ipratropium bromide
  • infliximab-dyyb
  • alclometasone dipropionate
  • interferon alfa-2b
  • aldesleukin
  • interferon alfacon-1
  • alectinib
  • interferon beta-1a
  • alemtuzumab
  • interferon beta-1b
  • alendronate sodium
  • interferon gamma-1b
  • alendronate sodium/cholecalciferol
  • ipilimumab
  • alirocumab
  • ipratropium bromide
  • alprazolam
  • ipratropium bromide/albuterol
  • altretamine
  • irbesartan
  • aminolevulinic acid
  • irbesartan/hydrochlorothiazide
  • amiodarone
  • irbesartan/hydrochlorothiazide tablet
  • amiodarone tablet
  • irinotecan
  • amiotic membrane allograft
  • isosorbide dinitrate
  • amlodipine besylate/atorvastatin calcium
  • isosorbide dinitrate/hydralazine tablet
  • amniotic membrane allograft
  • isotretinoin
  • anagrelide
  • isotretinoin capsule
  • anakinra injection
  • ivabradine tablet
  • anastrozole
  • ixabepilone
  • anthralin encapsulated cream
  • ixazomib
  • anthralin shampoo
  • ixekizumab
  • apomorphine
  • labetalol tablet
  • apremilast
  • lamivudine
  • aprepitant capsule
  • lamivudine/zidovudine
  • asparaginase erwinia chrysanthemi injection
  • lanreotide acetate
  • atazanavir sulfate
  • lanthanum carbonate
  • atazanavir sulfate/cobicistat
  • lapatinib ditosylate
  • atenolol
  • ledipasvir/sofosbuvir
  • atenolol/chlorthalidone
  • leflunomide
  • atezolizumab
  • lenalidomide
  • atorvastatin calcium
  • lenvatinib
  • atropine
  • letrozole
  • atropine sulfate
  • leucovorin calcium
  • auranofin
  • leuprolide acetate
  • axitinib
  • levalbuterol
  • azacitidine
  • levalbuterol tartrate
  • azathioprine
  • levoleucovorin calcium
  • azilsartan kamedoxomil/chlorthalidone tablet
  • levothyroxine
  • azilsartan medoxomil tablet
  • levothyroxine sodium
  • bacitracin zinc/neomycin sulfate/polymyxin b sulfate
  • lisinopril
  • baclofen
  • lomitapide
  • balsalazide disodium
  • lomustine
  • balsalazide disodium tablet
  • lopinavir/ritonavir
  • bazedoxifene acetate/conjugated estrogens
  • lorazepam
  • bcg (live)
  • losartan
  • becaplermin
  • losartan/hydrochlorothiazide
  • beclomethasone dipropionate
  • loteprednol etabonate/tobramycin ophthalmic suspension/drops
  • belinostat
  • lovastatin niacin tablet; extended release
  • benazepril
  • lovastatin tablet
  • bendamustine
  • lovastatin tablet; extended release
  • benztropine
  • maraviroc
  • betamethasone
  • matrix; human placental tissue
  • betamethasone dipropionate
  • matrix; lyophilized extracellular tissue matrix; extracellular
  • betamethasone dipropionate and calcipotriol
  • matrix; regenerative tissue
  • betamethasone valerate
  • matrix; tissue wound
  • bevacizumab
  • mechlorethamine
  • bexarotene gel; capsule
  • meclofenamate
  • bicalutamide
  • medical food
  • bilayered skin substitute
  • megestrol acetate
  • bisoprolol fumarate tablet
  • meloxicam
  • bisoprolol fumarate/hydrochlorothiazide
  • melphalan
  • bleomycin
  • mepolizumab
  • blinatumomab injection
  • mesalamine
  • bortezomib
  • mesna
  • bosutinib monohydrate
  • methotrexate
  • bovine collagen
  • methotrexate sodium
  • brentuximab vedotin
  • methoxsalen
  • brigatinib
  • methylprednisolone
  • brodalumab
  • methylprednisolone acetate
  • bromocriptine
  • methylprednisolone sodium succinate
  • budesonide
  • metoclopramide
  • budesonide/formoterol fumarate dihydrate
  • metoclopramide tablet; orally disintegrating
  • busulfan
  • metolazone
  • cabazitaxel
  • metoprolol succinate/hydrochlorothiazide tablet; extended release
  • cabozantinib s-malate
  • metoprolol sussinate
  • calcifediol
  • metoprolol tartrate
  • calcipotriene
  • metoprolol tartrate-hydrochlorothiazide tablet
  • calcipotriene aerosol; foam
  • metyrapone
  • calcipotriene hydrate-betamethasone dipropionate suspension; topical
  • midostaurin
  • calcitonin salmon
  • mifepristone
  • calcitonin salmon (rDNA origin)
  • miglustat
  • calcitriol
  • minocycline
  • calcium
  • mipomersen sodium
  • calcium acetate
  • mitomycin
  • calcium acetate oral solution
  • mitotane
  • candesartan cilexetil
  • moexipril
  • candesartan cilexetil/hydrochlorothiazide
  • moexipril/hydrochlorothiazide
  • capecitabine
  • mometasone
  • carbidopa tablet
  • mometasone furoate
  • carbidopa/levodopa
  • montelukast sodium
  • carbidopa/levodopa capsule; extended release
  • mycophenolate mofetil
  • carbidopa/levodopa sr tablet
  • nabilone capsule
  • carbidopa/levodopa tablet; extended release
  • nadolol tablet
  • carbidopa/levodopa tablet; orally disintegrating
  • nadolol/bendroflumethiazide
  • carbidopa/levodopa/entacapone
  • naproxen
  • carfilzomib
  • naproxen sodium
  • carmustine
  • naproxen/esomeprazole
  • carvedilol
  • natalizumab
  • celecoxib
  • nebivolol tablet
  • ceritinib
  • necitumumab
  • certolizumab pegol
  • nelarabine injection
  • cetuximab
  • nelfinavir
  • chlorambucil
  • neomycin sulfate/polymyxin B sulfate
  • chlorothiazide injection
  • neomycin sulfate/polymyxin B sulfate/dexamethasone
  • chlorothiazide suspension
  • netupitant/palonosetron capsule
  • cholestyramine
  • nevirapine
  • choline fenofibrate
  • nevirapine tablet; extended release
  • ciclesonide
  • niacin
  • cinacalcet
  • niacin tablet
  • clobetasol foam
  • niacin/simvastatin tablet; extended release
  • clobetasol propionate
  • nilotinib monohydrate
  • clobetasol propionate foam
  • nilutamide
  • clobetasol propionate lotion; shampoo; spray
  • nintedanib esylate
  • clocortolone pivalate cream
  • niraparib
  • clofarabine
  • nivolumab
  • cobicistat
  • obinutuzumab
  • cobimetinib
  • ocrelizumab
  • colesevelam
  • ocriplasmin
  • colestipol
  • octreotide acetate
  • conjugated estrogens
  • ofatumumab
  • conjugated synthetic a estrogens tablet
  • olanzapine
  • conjugated synthetic b estrogens tablet
  • olaparib
  • corticoreline ovine triflutate
  • olmesartan medoxomil
  • cortisone acetate
  • olsalazine sodium
  • crisaborole
  • omacetaxine mepesuccinate
  • crizotinib
  • omalizumab
  • cromolyn sodium
  • ombitasvir/paritaprevir/ritonavir and dasabuvir
  • cyclopentolate
  • ombitasvir/paritaprevir/ritonavir tablet
  • cyclosporine
  • ondansentron
  • cytarabine liposome
  • ondansetron
  • dabrafenib
  • osimertinib
  • daclatasvir
  • oxaliplatin
  • daclizumab
  • oxaprozin
  • dalfampridine
  • paclitaxel
  • daratumumab
  • palbociclib
  • darbepoetin alfa
  • palivizumab
  • darunavir ethanolate
  • palonosetron injection
  • darunavir ethanolate/cobicistat
  • pancrelipase
  • dasatinib
  • panitumumab
  • daunorubicin
  • panobinostat lactate
  • decitabine
  • paricalcitol
  • deferasirox
  • pasireotide
  • deferiprone
  • pasireotide diaspartate
  • deferoxamine
  • patiromer
  • degarelix acetate
  • pazopanib
  • delavirdine
  • pegaptanib sodium
  • denosumab
  • pegaspargase vial
  • dermal substitute
  • pegfilgrastim
  • desonide
  • peginterferon alfa-2a
  • desonide cream
  • peginterferon alfa-2a auto-injector
  • desonide gel
  • peginterferon alfa-2b
  • desoximetasone
  • peginterferon beta-1a
  • dexamethasone
  • pegvisomant
  • dexamethasone/neomycin sulfate/polymyxin B sulfate ophthalmic ointment
  • pembrolizumab
  • diazoxide
  • pemetrexed
  • diclofenac
  • penicillamine
  • diclofenac capsule
  • pentostatin
  • diclofenac epolamine patch
  • perindopril erbumine
  • diclofenac oral solution
  • pertuzumab
  • diclofenac potassium
  • phytonadione
  • diclofenac sodium
  • pimavanserin tablet
  • diclofenac sodium/misoprostol
  • pimecrolimus
  • didanosine
  • pirfenidone
  • diflorasone
  • piroxicam
  • diflorasone diacetate
  • pitavastatin tablet
  • difluprednate
  • placental membrane allograft
  • digoxin
  • plerixafor
  • digoxin tablet
  • pomalidomide
  • diltiazem
  • ponatinib
  • diltiazem capsule; extended release
  • porfimer sodium
  • diltiazem tablet; extended release
  • pralatrexate
  • dimethyl fumarate
  • pramipexole dihydrochloride
  • diphenhydramine
  • pravastatin sodium
  • disopyramide capsule
  • prednicarbate
  • disopyramide capsule; extended release
  • prednisolone
  • docetaxel
  • prednisolone acetate
  • dofetilide
  • prednisolone sodium phosphate
  • dolasetron
  • prednisone
  • dolutegravir sodium
  • procarbazine
  • doxercalciferol
  • prochlorperazine
  • doxorubicin
  • promethazine
  • dronabinol
  • propafenone
  • dronedarone tablet
  • propranolol
  • dupilumab
  • propranolol capsule; extended release
  • dyphylline
  • quinapril
  • dyphylline GG
  • quinidine
  • edetate calcium disodium
  • radium ra-223 dichloride
  • efavirenz
  • raloxifene
  • efavirenz/emtricitabine/tenofovir disoproxil fumarate
  • raltegravir
  • elbasvir/grazoprevir
  • ramipril
  • eliglustat tartrate
  • ramucirumab
  • elotuzumab
  • ranibizumab
  • eltrombopag
  • rasagiline
  • elvitegravir tablet
  • regorafenib
  • elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide
  • repository corticotropin
  • elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate
  • reslizumab
  • emtricitabine
  • ribavirin
  • emtricitabine/rilpivirine/tenofovir alafenamide
  • ribociclib
  • emtricitabine/rilpivirine/tenofovir disoproxil fumarate
  • ribociclib-letrozole tablet; co-pack
  • emtricitabine/tenofovir alafenamide
  • rifaximin
  • emtricitabine/tenofovir disoproxil fumarate
  • rilpivirine
  • enalapril maleate
  • rimexolone ophthalmic suspension/drops
  • enalapril maleate oral solution
  • risedronate sodium tablet
  • enalapril maleate/hydrochlorothiazide
  • risedronate sodium tablet; delayed release
  • enfuvirtide
  • ritonavir
  • entacapone
  • rituximab
  • enzalutamide
  • rivastigmine
  • epirubicin
  • rolapitant tablet
  • eplerenone tablet
  • romidepsin
  • epoetin alfa
  • romiplostim
  • eprosartan
  • ropinirole
  • eprosartan tablet
  • rosuvastatin calcium
  • ergocalciferol
  • rotigotine
  • eribulin
  • rucaparib
  • erlotinib
  • ruxolitinib
  • esmolol
  • sacubitril/valsartan tablet
  • estradiol
  • safinamide
  • estradiol cypionate
  • salicylic acid/sulfur/hydrocortisone
  • estradiol emulsion; topical
  • salmeterol xinafoate
  • estradiol film; transdermal system
  • samarium sm-153 lexidronam pentasodium
  • estradiol gel
  • saquinavir
  • estradiol spray
  • sargramostim
  • estradiol transdermal system
  • sarilumab
  • estradiol valerate
  • secukinumab
  • estrogens/esterified
  • selegiline
  • etanercept
  • selegiline tablet; orally disintegrating
  • etodolac
  • sevelamer
  • etomidate
  • sevelamer carbonate
  • etoposide
  • simeprevir sodium
  • etravirine
  • simvastatin
  • everolimus
  • sipuleucel-T
  • everolimus tablet
  • sirolimus
  • evolocumab
  • sodium polystyrene sulfonate
  • evolocumab auto-injector; pre-filled
  • sodium polystyrene sulfonate powder
  • exemestane
  • sofosbuvir
  • ezetimibe tablet
  • sofosbuvir/velpatasvir
  • ezetimibe/atorvastatin tablet
  • somatropin (rDNA origin)
  • ezetimibe/simvastatin tablet
  • somatropin (rDNA origin) injection
  • fenofibrate
  • somatropin recombinant
  • fenofibrate capsule
  • sonidegib capsule
  • fenofibrate tablet
  • sorafenib
  • fenofibric acid tablet
  • sotalol
  • fenoprofen calcium
  • sotalol oral solution
  • ferric citrate
  • sotalol tablet
  • filgrastim
  • spironolactone
  • filgrastim-sndz injection
  • spironolactone/hydrochlorothiazide tablet
  • fingolimod
  • stavudine
  • flecainide
  • streptozocin
  • flunisolide
  • strontium chloride SR-89
  • fluocinolone acetonide
  • succimer
  • fluocinolone acetonide implant
  • sucroferric oxyhydroxide
  • fluocinolone acetonide oil ear drops; otic
  • sulfacetamide sodium/prednisolone acetate
  • fluocinolone acetonide/hydroquinone/tretinoin
  • sulfasalazine
  • fluocinolone acetonide/neomycin sulfate
  • sunitinib malate
  • fluocinolone acetonisde
  • tacrolimus
  • fluocinonide cream; 0.1%
  • taliglucerase alfa
  • fluorometholone
  • talimogene laherparepvec
  • fluorometholone acetate ophthalmic suspension/drops
  • tamoxifen citrate
  • fluorouracil
  • tazarotene
  • fluoxymesterone
  • TBO-filgrastim
  • flurandrenolide
  • teduglutide (rDNA origin)
  • fluticasone furoate powder; inhalation
  • telmisartan
  • fluticasone furoate/vilanterol trifenatate
  • temozolomide
  • fluticasone propionate
  • temsirolimus
  • fluticasone propionate/salmeterol xinafoate
  • tenofovir disoproxil fumarate
  • fluvastatin capsule
  • teriflunomide
  • formoterol fumarate
  • teriparatide (rDNA origin)
  • formoterol fumarate/mometasone furoate
  • thalidomide
  • fosamprenavir calcium
  • theophylline
  • fosaprepitant dimeglumine injection
  • thyrotropin alfa
  • fulvestrant
  • tiotropium bromide powder; inhalation
  • furosemide
  • tiotropium bromide spray
  • gefitinib
  • tiotropium bromide/olodaterol spray
  • gemcitabine
  • tipranavir
  • gemfibrozil
  • tissue; human allograft
  • gentamicin sulfate/prednisolone acetate
  • tizanidine
  • glatiramer acetate
  • tobramycin/dexamethasone
  • glutamine
  • tocilizumab
  • golimumab
  • tofacitinib
  • goserelin acetate
  • tolcapone tablet
  • gramicidin/neomycin sulfate/polymyxin b sulfate
  • tolmetin sodium
  • granisetron
  • topotecan
  • granisetron oral solution
  • toremifene citrate
  • granisetron transdermal patch
  • torsemide
  • halcinonide
  • trametinib dimethyl sulfoxide
  • halobetasol propionate
  • trandolapril
  • haloperidol
  • trastuzumab
  • histrelin implant
  • tretinoin
  • homatropine
  • triamcinolone
  • human amniotic membrane
  • triamcinolone acetonide
  • human skin allograft
  • triamterene capsule
  • hydralazine
  • trientine
  • hydrochlorothiazide
  • trifluridine and tipiracil
  • hydrochlorothiazide/lisinopril
  • trihexyphenidyl
  • hydrochlorothiazide/losartan
  • triptorelin
  • hydrochlorothiazide/olmesartan medoxomil
  • ustekinumab
  • hydrochlorothiazide/quinapril
  • valsartan
  • hydrochlorothiazide/telmisartan tablet
  • valsartan/hydrochlorothiazide
  • hydrochlorothiazide/triamterene
  • vandetanib
  • hydrocortisone
  • vedolizumab
  • hydrocortisone acetate
  • velaglucerase alfa
  • hydrocortisone acetate/urea
  • vemurafenib
  • hydrocortisone butyrate lotion
  • venetoclax
  • hydrocortisone probutate
  • verapamil
  • hydrocortisone sodium succinate
  • verteporfin
  • hydrocortisone valerate
  • vigabatrin
  • hydrocortisone/neomycin/polymyxin b sulfate
  • vincristine
  • hydrocortizone
  • vincristine sulfate
  • hydroxychloroquine
  • vinorelbine tartrate
  • hydroxyurea
  • vismodegib
  • hydroxyzine
  • vitamin A supplement
  • ibandronate sodium
  • vorinostat
  • ibritumomab tiuxetan
  • wound dressing
  • ibrutinib
  • wound matrix
  • ibuprofen
  • zafirlukast
  • ibuprofen/famotidine
  • zidovudine
  • ibutilide fumarate injection
  • zileuton
  • idelalisib
  • zinc acetate
  • ifosfamide
  • ziv-aflibercept
  • ifosfamide/mesna
  • zoledronic acid
  • imatinib
 

Eligibility Requirements   

Insurance Status *See Additional Information section below
Those with Part D Eligible? Determined case by case
Income Between 400-500% 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 Complete online or by phone
Returning Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
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

*Patients must have health insurance and their insurance must cover the qualifying medication for which they seek assistance.

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.

Note: All new enrollment is now done electronically or over the phone. Contact program for details.


Updated June 29, 2017