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

American Regent IV Iron Patient Assistance Program

For Healthcare Professionals Only

Provided by: American Regent, Inc.

American Regent Iron Patient Assistance Program
C/O InTeleCenter
PO Box 4280
Gaithersburg, MD 20885-4133

TEL: 877-448-4766


FAX: 240-632-3805
Languages Spoken:

English, Others By Translation Service

Program Website

 

Patient Assistance Applications

American Regent IV Iron Patient Assistance Program Enrollment Application

American Regent Patient Assistance Program Product Request Form

 

Brand Name Medications Covered

 
  • Injectafer injection
  • Venofer
 

Generic Name

 
  • ferric carboxymaltose injection
  • iron sucrose
 

Eligibility Requirements   

Insurance Status Must not have any insurance or be eligible for state or federal funded healthcare
Those with Part D Eligible? No, must be ineligible
Income Not disclosed
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Patient/Doctor's office must 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 and provide annual income information. Proof of income required
Decision Communicated Doctor notified
Decision Timeframe Up to 10 business days
   

Medication

Amount/Supply Varies
Sent To Doctor's office
Delivery Time Within 4-6 weeks
Refill Process Reorder form needs to be submitted
Limit Contact the program for details
Re-application New application yearly
   

Additional Information

*See Injectafer Coding Guide provided on the program website.

This program also provides co-pay and reimbursement assistance.


Updated September 28, 2018