Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
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Hematology Support Center

This program provides brand name medications at no or low cost

Provided by: Takeda Pharmaceutical


TEL: 888-229-8379


FAX: 866-467-7740
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Hematology Support Center Enrollment Form

Takeda Expands Assistance During COVID-19 Crisis Information Letter

 

Medications

  • antihemophilic factor human injection (Hemofil-M) Injection
 

Eligibility Requirements   

Insurance Status Must be commercially insured
Those with Part D Eligible? No
Income Not applicable
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call, download or apply online
Receiving Complete online, download from website or faxed.
Returning Fax, mail or submit online
Doctor's Action Varies
Applicant's Action Call or enroll online
Decision Communicated Patient and Doctor are notified
Decision Timeframe 2 business days, once application process is complete
   

Medication

Amount/Supply Not specified
Sent To Varies
Delivery Time Not specified
Refill Process Varies per medication
Limit Not specified
Re-application Contact program for details.
   

Additional Information

Eligibility determined on a case-by-case basis.

Free Trial Program, Patient Assistance Programs and Co-payment Assistance are available for eligible patients. Contact program for details.

This program also provides copay assistance.

Updated September 14, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
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My Source CSL Behring Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: CSL Behring


TEL: 800-676-4266


ALT PHONE: 844-727-2752
Languages Spoken:

English

Program Website

 

Program Applications and Forms

My Source CSL Behring Patient Assistance Program Application

 

Medications

  • antihemophilic factor (human) vial; single-use (Monoclate-P) Vial; Single-Use
 

Eligibility Requirements   

Insurance Status Must be uninsured or underinsured
Those with Part D Eligible? Contact program for details.
Income At or below 250% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside in the US
   

Application

Obtaining Call
Receiving Faxed, emailed or mailed
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach proof of income and include Medicaid denial letter
Decision Communicated Not specified
Decision Timeframe Not specified
   

Medication

Amount/Supply Contact the program for more details.
Sent To Doctor's office, hospital, or pharmacy
Delivery Time Contact Program for Details
Refill Process Contact program for details.
Limit Contact the program for details
Re-application Contact program for details.
   

Additional Information

This program also provides copay assistance.

Call for most recent medications as the list is subject to change: 1-844-727-2752

Updated August 14, 2020


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

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

  • antihemophilic factor (human) injection
  • antihemophilic factor human injection
  • antihemophilic factor (human) vial; single-use
 

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 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

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

*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 September 28, 2020