| 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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Sanofi Patient ConnectionThis program provides brand name medications at no or low cost |
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Provided by: Sanofi |
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PO Box 222138 TEL: 888-847-4877FAX: 888-847-1797 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Sanofi Patient Connection Program Application |
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Sanofi Patient Connection Program Application (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? | Contact program for details. | ||
| Income | At or below 400% of FPL | ||
| Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | ||
| US Residency Required? | Must be residing in the US or a US territory, and under the care of a US physician | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed, mailed or downloaded from website | ||
| Returning | Fax, mail or via Online Portal | ||
| Doctor's Action | Complete section, sign, attach required documents | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient and Doctor are notified | ||
| Decision Timeframe | 2-4 business days | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Doctor's office | ||
| Delivery Time | Within 5-7 business days | ||
| Refill Process | Reorder form needs to be submitted | ||
| Limit | Contact the program for details | ||
| Re-application | New application, new documentation yearly | ||
Additional Information |
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| Healthcare provider must contact the Program for REORDER FORMS. This program may provide a Bridge Program for eligible patients who experience a delay, temporary loss, or change in coverage. Contact program for details. |
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| Updated June 16, 2023 | |||
| 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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HealthWell Foundation Copay ProgramThis is a copay assistance program |
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Provided by: HealthWell Foundation |
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TEL: 800-675-8416 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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HealthWell Foundation Copay Program Enrollment: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | May have insurance | ||
| Those with Part D Eligible? | Yes, but contact program for details | ||
| Income | Varies | ||
| Diagnosis/Medical Criteria | FDA Approved Diagnosis - See Program Website for Details | ||
| US Residency Required? | Must reside in the US | ||
Application |
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| Obtaining | Call or complete online | ||
| Receiving | Varies | ||
| Returning | |||
| Doctor's Action | Complete section and sign | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient notified | ||
| Decision Timeframe | 3-5 business days | ||
Medication |
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| Amount/Supply | Not applicable | ||
| Sent To | Varies | ||
| Delivery Time | Not specified | ||
| Refill Process | Automatically sent out | ||
| Limit | Contact the program for details | ||
| Re-application | New application every 12 months | ||
Additional Information |
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| This program provides financial assistance to eligible individuals to cover coinsurance, copayments, healthcare premiums and deductibles for certain treatments. Also, for those who are eligible for health insurance, but cannot afford the insurance premium, the foundation may be able to help by paying some or all of the medical portion of insurance premiums. The patient is being treated for a specific disease for which funding is available and has insurance that covers the treatment for this disease. Call for most recent medications as the list is subject to change. |
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| Updated September 13, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 3. | |||
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 | FDA Approved Diagnosis - See Program Website for Details | ||
| 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 | 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 |
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| 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 |
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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 September 06, 2023 | |||
