Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
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Sebela Patient Assistance Program: Lotronex & Ridaura

This program provides brand name medications at no or low cost

Provided by: Sebela Pharmaceuticals Inc.

50 Whittemore Street
Gloucester, MA 01930

TEL: 866-562-7902


FAX: 888-246-6527 		Languages Spoken:

English

Program Website

 

Program Applications and Forms

Sebela Patient Assistance Program Application: Lotronex

Sebela Patient Assistance Program Application: Ridaura
 

Medications
  • auranofin (Ridaura) 
 

Eligibility Requirements   
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
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
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
* 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.
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

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
  • auranofin (Ridaura) 
 

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 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
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
*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 June 05, 2023