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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Sebela Patient Assistance Program: Lotronex & RidauraThis program provides brand name medications at no or low cost @if> |
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Provided by: Sebela Pharmaceuticals Inc. |
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50 Whittemore Street TEL: 866-562-7902FAX: 888-246-6527 |
Languages Spoken:
English |
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Program Applications and Forms |
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Sebela Patient Assistance Program Application: Lotronex |
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Sebela Patient Assistance Program Application: Ridaura |
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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. *See Additional Information Section Below | ||
Income | At or below 300% of FPL | ||
Diagnosis/Medical Criteria | Medically appropriate condition/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 or download | ||
Receiving | Faxed, emailed, mailed or downloaded | ||
Returning | Email, fax or mail | ||
Doctor's Action | Complete section and sign | ||
Applicant's Action | Complete section, sign, attach required documents | ||
Decision Communicated | Patient notified | ||
Decision Timeframe | 5-7 business days | ||
Medication |
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Amount/Supply | Contact the program for more details. | ||
Sent To | Doctor's office or patient's home | ||
Delivery Time | Once approved; shipped next business day | ||
Refill Process | Contact program for details. | ||
Limit | None | ||
Re-application | New prescription every 3 months. New application every 6 months. | ||
Additional Information |
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* Must not have Health insurance coverage (private or government) that pays for requested products and haven’t for at least three months. **Medicare Part D - Copy of insurance denial letter required. ***The manufacturer supporting this program does not charge for applying to the program nor for any products applicants receive. Applicants using the services of a commercial advocacy service may have to supply additional documentation. |
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Updated May 22, 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 @if> |
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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 June 05, 2023 |