| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 3. Scroll down to see them all. |
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View Coupon |
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AbbVie Patient Assistance Program for HUMIRAThis program provides brand name medications at no or low cost |
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Provided by: AbbVie |
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D-617927, AP5 NE TEL: 800-222-6885FAX: 866-250-2803 |
Languages Spoken:
English, Spanish, Others by Translation Service |
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Program Applications and Forms |
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AbbVie Patient Assistance Application for HUMIRA |
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AbbVie Patient Assistance Application for HUMIRA (Spanish) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must have no prescription coverage for needed medication | ||
| Those with Part D Eligible? | Considered on exception basis | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Open to all diagnoses | ||
| US Residency Required? | Must be treated by US Doctor | ||
Application |
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| Obtaining | Call | ||
| Receiving | Faxed or mailed | ||
| Returning | Fax or mail | ||
| Doctor's Action | Complete section and sign | ||
| Applicant's Action | Complete section, sign, attach proof of income and any insurance information | ||
| Decision Communicated | Patient and Doctor notified of acceptance | ||
| Decision Timeframe | Within 24-48 hours | ||
Medication |
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| Amount/Supply | Up to 90 day supply | ||
| Sent To | Doctor's office or patient's home | ||
| Delivery Time | Within 3-5 business days | ||
| Refill Process | Patient or Doctor must contact company | ||
| Limit | Not specified | ||
| Re-application | New application, new documentation yearly | ||
Additional Information |
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| Patients with prescription drug coverage may be eligible on exception basis. |
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| Updated January 23, 2019 | |||
| 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. |
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View Coupon |
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Good Days ProgramThis is a copay assistance program |
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Provided by: Good Days from CDF |
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Attn: Enrollment TEL: 877-968-7233FAX: 214-570-3621 |
Languages Spoken:
English |
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Program Applications and Forms |
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Good Days Program Patient Enrollment Application (pages: 3-5) |
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Good Days Program Enrollment Information Pages (pages: 1 & 2) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Not specified | ||
| Those with Part D Eligible? | Not specified | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Not specified | ||
| US Residency Required? | Not specified | ||
Application |
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| Obtaining | Call, download or apply online | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax, mail or submit online | ||
| Doctor's Action | Give prescription to patient | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient and/or Doctor are notified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | Not specified | ||
| Sent To | Not specified | ||
| Delivery Time | Not specified | ||
| Refill Process | Not specified | ||
| Limit | Not specified | ||
| Re-application | Must re-enroll at end of calendar year | ||
Additional Information |
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| 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. |
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| Updated October 05, 2018 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 3. | |||
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View Coupon |
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Patient Access Network Foundation (PAN)This is a copay assistance program |
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Provided by: Patient Access Network Foundation |
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TEL: 866-316-7263FAX: 866-316-7261 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Patient Access Network Foundation (PAN) Application: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| *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. |
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| Updated January 04, 2019 | |||
