| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 1 of 2. Scroll down to see them all. |
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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 August 05, 2022 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 2. | |||
Circle of Care Patient Assistance ProgramFor Healthcare Professionals Only |
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Provided by: Organogenesis Inc. |
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TEL:FAX: 866-212-2888 |
Languages Spoken:
English |
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Program Applications and Forms |
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Circle of Care Patient Assistance Program Application |
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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 disclosed | ||
| Diagnosis/Medical Criteria | Medically Necessary as determined by a Doctor | ||
| US Residency Required? | Must reside in the US | ||
Application |
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| Obtaining | Doctor/Doctor's office must call | ||
| 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 | Doctor notified | ||
| Decision Timeframe | Within 2-3 days | ||
Medication |
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| Amount/Supply | Not specified | ||
| Sent To | Doctor's office | ||
| Delivery Time | Within 2 business days | ||
| Refill Process | Contact company, determined on case by case basis | ||
| Limit | Contact the program for details | ||
| Re-application | Contact program for details. | ||
Additional Information |
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| Resources for HEALTHCARE PROFESSIONALS ONLY. Contact program for more details: www.Apligraf.com or www.Dermagraft.com |
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| Updated July 14, 2022 | |||
