Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Mirati & Me Patient Support Program

This program provides brand name medications at no or low cost

Provided by: Mirati Therapeutics, Inc.


TEL: 844-647-2842


FAX: 844-647-2844
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Mirati & Me Patient Support Program Enrollment Form

Mirati & Me Patient Support Program Enrollment Form (Spanish)

Mirati & Me Patient Brochure

 

Medications

  • adagrasib tablet (Krazati) Tablet
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Not specified
Income Based on FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US and be under the direct care of a US physician
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Fax from Doctor's office
Doctor's Action Complete section, sign, attach required documents
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Varies
Delivery Time Varies
Refill Process Contact program for details.
Limit Varies
Re-application
   

Additional Information

Co-payment assistance, patient support, and patient assistance programs are available for eligible patients.

Free Trial Program: Contact Program for details.

This program may provide a Bridge Program for eligible patients who experience a delay, temporary loss, or change in coverage. Contact program for details.

Updated November 15, 2023


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 2.
 

Patient Access Network Foundation (PAN)

This is a copay assistance program

Provided by: Patient Access Network Foundation


TEL: 866-316-7263


FAX: 866-316-7261
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Patient Access Network Foundation (PAN) Application: Contact program

 

Medications

  • adagrasib tablet (Krazati) Tablet
 

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 FDA Approved Diagnosis - See Program Website for Details
US Residency Required? Must reside and receive treatment in US
   

Application

Obtaining Call or complete online
Receiving Complete online or by phone
Returning Not applicable
Doctor's Action Varies
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor are notified
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient is sent savings 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 February 21, 2024