Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
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Dova 1Source

This program provides brand name medications at no or low cost

Provided by: Dova Pharmaceuticals, Inc.

PO Box 5490
Louisville, KY 40255

TEL: 833-368-2663


FAX: 855-686-8729
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Dova 1Source Patient Enrollment Form and Statement of Medical Necessity

Dova 1Source Patient Authorization and Consent Form

 

Medications

  • avatrombopag tablet (Doptelet) Tablet
 

Eligibility Requirements   

Insurance Status Uninsured or Underinsured
Those with Part D Eligible? Contact program for details.
Income Based on FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must be a legal resident of the United States or its territories
   

Application

Obtaining Call, download or apply online
Receiving Faxed or downloaded from website
Returning Fax or E-Prescribe online
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

Amount/Supply Varies
Sent To Patient's home, unless otherwise noted
Delivery Time Varies
Refill Process Not specified
Limit Not specified
Re-application Not specified
   

Additional Information

Co-payment assistance and patient assistance programs are available for eligible patients.

Updated August 18, 2020


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

  • avatrombopag tablet (Doptelet) Tablet
 

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 Complete online or by phone
Doctor's Action Will be discussed with patient and Doctor after request is received
Applicant's Action Call for information or inform doctor that he/she is in need
Decision Communicated Patient and Doctor notified in writing
Decision Timeframe Within 48 hours
   

Medication

Amount/Supply Not applicable
Sent To Patient sent 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 September 28, 2020