| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 8. Scroll down to see them all. |
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Afstyla ConnectThis program provides brand name medications at no or low cost |
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Provided by: CSL Behring |
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TEL: 800-676-4266ALT PHONE: 844-727-2752 FAX: 844-727-2757 |
Languages Spoken:
English |
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Program Applications and Forms |
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Afstyla Connect Enrollment Form |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Contact program for details. | ||
| Those with Part D Eligible? | Contact program for details. | ||
| Income | Based on FPL | ||
| Diagnosis/Medical Criteria | FDA-approved diagnosis | ||
| US Residency Required? | Must be residing in the US or US territory | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed, emailed, mailed or downloaded | ||
| 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 | Patient and Doctor are notified | ||
| Decision Timeframe | Not specified | ||
Medication |
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| Amount/Supply | Contact the program for more details. | ||
| Sent To | Varies | ||
| 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 |
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| Co-payment assistance, reimbursement support, patient support, and patient assistance programs are available for eligible patients. Program provides medically necessary therapy to qualified individuals who are uninsured, underinsured, or unable to afford their therapy. |
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| Updated December 12, 2022 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 8. Scroll down to see them all. |
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Bayer US Patient Assistance Foundation Free Drug ProgramThis program provides brand name medications at no or low cost |
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Provided by: Bayer US Patient Assistance Foundation |
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PO Box 5670 TEL: 866-228-7723FAX: 866-575-6568 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Bayer US Patient Assistance Foundation Free Drug Program Application |
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Bayer US Patient Assistance Foundation Free Drug 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? | No | ||
| Income | Not disclosed | ||
| Diagnosis/Medical Criteria | Medically appropriate condition/diagnosis | ||
| US Residency Required? | Must be residing in the US or Puerto Rico | ||
Application |
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| 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 |
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| Amount/Supply | Varies | ||
| Sent To | Varies | ||
| Delivery Time | Not specified | ||
| Refill Process | Doctor/Doctor's office must contact the Program | ||
| Limit | Not specified | ||
| Re-application | New application, new documentation yearly | ||
Additional Information |
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| Eligibility determined on a case-by-case basis. |
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| Updated May 04, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 3 of 8. Scroll down to see them all. |
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CSL Behring Support & Assistance ProgramsThis program provides brand name medications at no or low cost |
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Provided by: CSL Behring |
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TEL: 844-727-2752 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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CSL Behring Support & Assistance Programs Forms: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Determined case by case | ||
| Those with Part D Eligible? | Contact program for details. | ||
| Income | Based on FPL | ||
| Diagnosis/Medical Criteria | FDA-approved diagnosis | ||
| US Residency Required? | Must reside in the US | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Varies | ||
| 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 | Varies | ||
Medication |
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| Amount/Supply | Contact the program for more details. | ||
| Sent To | Varies | ||
| Delivery Time | Varies | ||
| Refill Process | Varies per medication | ||
| Limit | Varies | ||
| Re-application | Varies | ||
Additional Information |
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| Since drug availability changes based on inventory, call to make sure requested drug is available. |
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| Updated April 14, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 4 of 8. Scroll down to see them all. |
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Hematology Support Center Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Takeda Pharmaceutical |
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Takeda's Patient Assistance Program TEL: 888-229-8379FAX: 866-467-7740 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Hematology Support Center Patient Assistance Program Application |
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Hematology Support Center Patient Assistance Program Application (Spanish) |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Must be uninsured | ||
| 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 |
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| Obtaining | Call, download or apply online | ||
| Receiving | Complete online, download from website or faxed. | ||
| Returning | Fax, mail or submit online | ||
| 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 business days, once application process is complete | ||
Medication |
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| Amount/Supply | Not specified | ||
| Sent To | Varies | ||
| Delivery Time | Not specified | ||
| Refill Process | Varies per medication | ||
| Limit | Contact the program for details | ||
| Re-application | New application yearly | ||
Additional Information |
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| 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. |
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| Updated April 28, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 5 of 8. Scroll down to see them all. |
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Novo Nordisk Rare Blood Disorders Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Novo Nordisk |
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501 West Church Street, Suite 450 TEL: 844-668-6732FAX: 866-488-6576 |
Languages Spoken:
English, Spanish, Others By Translation Service |
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Program Applications and Forms |
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Novo Nordisk Rare Blood Disorders Patient Assistance Program: Contact program |
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Medications |
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Eligibility Requirements |
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| 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 |
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| Obtaining | Call or download | ||
| Receiving | Faxed or downloaded from website | ||
| Returning | Email, fax or mail | ||
| 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 | 7-10 business days | ||
Medication |
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| Amount/Supply | Varies | ||
| Sent To | Doctor's office or patient's home | ||
| 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 |
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| Co-payment assistance, and patient assistance programs are available for eligible patients. Free Trial Program: Contact Program for details |
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| Updated May 15, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 6 of 8. Scroll down to see them all. |
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Pfizer Hemophilia Connect (PHC) Patient Assistance ProgramThis program provides brand name medications at no or low cost |
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Provided by: Pfizer, Inc. |
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TEL: 844-989-4366 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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Pfizer Hemophilia Connect Patient Assistance Program Enrollment Information: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Contact program for details. | ||
| Those with Part D Eligible? | Yes, but contact program for details | ||
| Income | At or below 500% of FPL | ||
| Diagnosis/Medical Criteria | FDA-approved 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 | ||
| Receiving | Faxed or mailed | ||
| Returning | Not specified | ||
| 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 |
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| 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 | Contact the program for details | ||
| 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 |
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| Updated March 28, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 7 of 8. Scroll down to see them all. |
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Pfizer RxPathwaysThis program provides patient support assistance |
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Provided by: Pfizer, Inc. |
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TEL: 844-989-7284 |
Languages Spoken:
English, Spanish |
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Program Applications and Forms |
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Pfizers RxPathways: Contact program |
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Medications |
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Eligibility Requirements |
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| Insurance Status | Contact program for details. | ||
| Those with Part D Eligible? | Yes, but contact program for details | ||
| Income | Varies | ||
| Diagnosis/Medical Criteria | FDA-approved diagnosis | ||
| US Residency Required? | Must be residing in the US or US territory | ||
Application |
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| Obtaining | Call for prescreening or apply online | ||
| Receiving | Varies | ||
| Returning | Varies | ||
| Doctor's Action | Varies | ||
| Applicant's Action | Call or enroll online | ||
| Decision Communicated | Not specified | ||
| Decision Timeframe | Varies | ||
Medication |
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| Amount/Supply | Contact the program for more details. | ||
| Sent To | Varies | ||
| Delivery Time | Varies | ||
| Refill Process | Varies per medication | ||
| Limit | Contact the program for details | ||
| Re-application | Contact program for details. | ||
Additional Information |
|||
| Co-payment assistance, and patient assistance programs are available for eligible patients. Call for most recent medications as the list is subject to change. |
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| Updated March 28, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 8 of 8. | |||
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 May 30, 2023 | |||
