| 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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JazzCares: RylazeThis program provides brand name medications at no or low cost |
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Provided by: Jazz Pharmaceuticals, Inc. |
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JazzCares Program TEL: 833-533-5299FAX: 855-593-3955 |
Languages Spoken:
English |
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Program Applications and Forms |
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JazzCares: Rylaze Enrollment Form |
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JazzCares: Rylaze Patient Authorization Form |
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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 | At or below 400% of FPL | ||
| Diagnosis/Medical Criteria | FDA-approved diagnosis | ||
| US Residency Required? | Must be a US resident and treated by a US licensed healthcare provider | ||
Application |
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| Obtaining | Call or download | ||
| Receiving | Faxed or downloaded from website | ||
| Returning | Fax, mail or submit online | ||
| Doctor's Action | Give prescription to patient | ||
| Applicant's Action | Complete section, sign, attach required documents | ||
| Decision Communicated | Patient notified | ||
| Decision Timeframe | 2-3 business days | ||
Medication |
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| Amount/Supply | Up to 1 month supply | ||
| Sent To | Not specified | ||
| Delivery Time | Once approved; within 2 business days | ||
| Refill Process | Company contacts patient to arrange | ||
| Limit | Contact the program for details | ||
| Re-application | Contact program for details. | ||
Additional Information |
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| Eligibility determined on a case-by-case basis. Co-payment assistance, and patient assistance programs are available for eligible patients. |
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| Updated May 18, 2023 | |||
| Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis. | |||
| Program 2 of 2. | |||
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 | |||
