Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 6.
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Bayer US Patient Assistance Foundation Free Drug Program

This program provides brand name medications at no or low cost

Provided by: Bayer US Patient Assistance Foundation

PO Box 5670
Louisville, KY 40255

TEL: 866-228-7723


FAX: 866-575-6568
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Bayer US Patient Assistance Foundation Free Drug Program Application

Bayer US Patient Assistance Foundation Free Drug Program Application (Spanish)

 

Medications

  • antihemophilic factor (recombinant) injection; iv lyophilized powder (Kovaltry) Injection; IV Lyophilized powder
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed medication
Those with Part D Eligible? No
Income Not disclosed
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be residing in the US or Puerto Rico
   

Application

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

Medication

Amount/Supply Varies
Sent To Varies
Delivery Time Not specified
Refill Process Doctor/Doctor's office must complete replacement form
Limit Not specified
Re-application New application, new documentation yearly
   

Additional Information

Eligibility determined on a case-by-case basis.

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 6.
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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 (recombinant) injection; iv lyophilized powder (Recombinate) Injection; IV Lyophilized powder
 

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 3 of 6.
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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 (recombinant) injection; iv lyophilized powder (Afstyla) Injection; IV Lyophilized powder
 

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 4 of 6.
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NovoSecure

This program provides brand name medications at no or low cost

Provided by: Novo Nordisk

PO Box 18648
Louisville, KY 40261-9961

TEL: 844-668-6732


FAX: 866-488-6576
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Novo Nordisk Product Assistance Application (pages 3-6)

Novo Nordisk Eligibility and Instructions (pages 1-2)

 

Medications

  • antihemophilic factor recombinant injection; iv lyophilized powder (Novoeight) Injection; IV Lyophilized powder
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income At or below 400% of FPL
Diagnosis/Medical Criteria Medically appropriate condition/diagnosis
US Residency Required? Must be citizen or legal resident
   

Application

Obtaining Call or download
Receiving Faxed or downloaded from website
Returning Email or fax
Doctor's Action Complete section and sign
Applicant's Action Complete section, sign, attach required documents
Decision Communicated Patient and Doctor are notified
Decision Timeframe 7-10 business days
   

Medication

Amount/Supply Varies
Sent To Patient's home
Delivery Time Not specified
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Free Trial Program: Contact Program for details

Updated September 10, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 5 of 6.
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Pfizer Hemophilia Connect (PHC) Patient Assistance Program

This program provides brand name medications at no or low cost

Provided by: Pfizer, Inc.


TEL: 844-989-4366


ALT PHONE: 844-989-7284
Languages Spoken:

English, Spanish

Program Website

 

Program Applications and Forms

Pfizer Hemophilia Connect Patient Assistance Program Enrollment Information: Contact program

 

Medications

  • antihemophilic factor (recombinant) injection; iv (Xyntha) Injection; IV
 

Eligibility Requirements   

Insurance Status Must have no prescription coverage for needed product
Those with Part D Eligible? Not specified
Income Not disclosed
Diagnosis/Medical Criteria Not specified
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application

Obtaining Call
Receiving Faxed or mailed
Returning Fax or mail 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 Amount requested is sent
Sent To Doctor's office or patient's home
Delivery Time Varies
Refill Process Contact program for details.
Limit Not specified
Re-application New application yearly
   

Additional Information

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

Free Trial Program: Contact Program for details

Updated July 08, 2020


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 6 of 6.
 

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 (recombinant) injection; iv
  • antihemophilic factor recombinant injection; iv lyophilized powder
  • antihemophilic factor (recombinant) injection; iv lyophilized powder
 

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