| 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. |
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Doptelet ConnectThis program provides brand name medications at no or low cost |
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Provided by: Sobi, Inc. |
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TEL: 833-368-2663FAX: 855-686-8729 |
Languages Spoken:
English, Others By Translation Service |
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Program Applications and Forms |
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Doptelet Connect Prescription and Enrollment Form |
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Doptelet Connect Prescription and Enrollment Form (Spanish) |
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Doptelet Connect Patient/Authorized Representative Consent Form |
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Doptelet Connect Patient/Caregiver Consent Form (Spanish) |
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Medications |
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Eligibility Requirements |
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| 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 |
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| Obtaining | Call or download | ||
| Receiving | Faxed or downloaded from website | ||
| Returning | Fax | ||
| 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 |
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| 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 |
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| Co-payment assistance and patient assistance programs are available for eligible patients. |
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| Updated February 16, 2023 | |||
| 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. |
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Good Days ProgramThis is a copay assistance program |
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Provided by: Good Days from CDF |
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Attn: Enrollment TEL: 877-968-7233FAX: 214-570-3621 |
Languages Spoken:
English |
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Program Applications and Forms |
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Good Days Program Patient Enrollment Application (pages 3-5) |
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Good Days Program Enrollment Information Pages (pages 1 & 2) |
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Good Days Program Patient Enrollment Application (pages 3-5) (Spanish) |
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Good Days Program Enrollment Information Pages (pages 1 & 2) (Spanish) |
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Medications |
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Eligibility Requirements |
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| 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 |
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| 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 |
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| 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 |
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| 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. |
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| Updated March 22, 2023 | |||
| 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 |
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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 | |||
