Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 3.
Scroll down to see them all.
 

Doptelet Connect

This program provides brand name medications at no or low cost

Provided by: Sobi, Inc.


TEL: 833-368-2663


FAX: 855-686-8729
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Doptelet Connect Prescription and Enrollment Form

Doptelet Connect Prescription and Enrollment Form (Spanish)

Doptelet Connect Patient/Caregiver Consent Form

Doptelet Connect Patient/Caregiver Consent Form (Spanish)

 

Medications

  • avatrombopag tablet (Doptelet) Tablet
 

Eligibility Requirements   

Insurance Status Must be 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 or download
Receiving Faxed or downloaded from website
Returning Fax
Doctor's Action Complete section and sign
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 Contact the program for details
Re-application New application yearly
   

Additional Information

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

Updated July 13, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 2 of 3.
Scroll down to see them all.
 

Good Days Program

This is a copay assistance program

Provided by: Good Days from CDF

Attn: Enrollment
2611 Internet Blvd.
Suite 105
Frisco, TX 75034

TEL: 877-968-7233


FAX: 214-570-3621
Languages Spoken:

English

Program Website

 

Program Applications and Forms

Good Days Program Patient Enrollment Application (pages 3-5)

Good Days Program Enrollment Information Pages (pages 1 & 2)

Good Days Program Patient Enrollment Application (pages 3-5) (Spanish)

Good Days Program Enrollment Information Pages (pages 1 & 2) (Spanish)

 

Medications

  • avatrombopag tablet (Doptelet) Tablet
 

Eligibility Requirements   

Insurance Status Must have insurance
Those with Part D Eligible? Not specified
Income At or below 500% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Yes and have social security number
   

Application

Obtaining Call, download or apply online
Receiving Faxed, mailed 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 and/or Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply Not specified
Sent To Not specified
Delivery Time Not specified
Refill Process Not specified
Limit Contact the program for details
Re-application Must re-enroll at end of calendar year
   

Additional Information

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.

Updated June 09, 2022


Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 3 of 3.
 

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 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 August 05, 2022