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

ARCH Patient Assistance Program for Skyla, Mirena, and Kyleena

Provided by: Bayer HealthCare Pharmaceuticals Inc.

PO Box 29061
Phoenix, AZ 85038

TEL: 877-393-9071


FAX: 877-229-1421
Languages Spoken:

English

Program Website

 

Patient Assistance Applications

ARCH Patient Assistance Program Application Form

ARCH Patient Assistance Program Application Form (Spanish)

 

Brand Name Medications Covered

 
  • Kyleena intrauterine system
  • Skyla intrauterine
  • Mirena contraceptive system
 

Generic Name

 
  • levonorgestrel intrauterine
  • levonorgestrel-releasing intrauterine system contraceptive system
  • levonorgestrel intrauterine system
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? Not specified
Income Based on FPL
Diagnosis/Medical Criteria Not specified
US Residency Required? Must reside in the US, Puerto Rico or the USVI
   

Application

Obtaining Call or download
Receiving Faxed, mailed or downloaded from website
Returning Fax or mail
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe 5-7 business days
   

Medication

Amount/Supply Amount requested is sent
Sent To Doctor's office
Delivery Time Not specified
Refill Process Not specified
Limit None
Re-application Not specified
   

Additional Information


Updated November 03, 2017