Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
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Kyowa Kirin Cares Patient Assistance Program (Poteligeo)

This program provides brand name medications at no or low cost

Provided by: Kyowa Kirin


TEL: 833-552-2737


FAX: 844-267-5848
Languages Spoken:

English, Others By Translation Service

Program Website

 

Program Applications and Forms

Kyowa Kirin Cares Patient Assistance Program (Poteligeo) Application

 

Medications

  • mogamulizumab-KPKC injection; iv (Poteligeo) Injection; IV
 

Eligibility Requirements   

Insurance Status Must be uninsured
Those with Part D Eligible? No
Income At or below 400% of FPL
Diagnosis/Medical Criteria FDA-approved diagnosis
US Residency Required? Must reside permanently in the US or US territories
   

Application

Obtaining Call or download
Receiving Faxed
Returning Fax
Doctor's Action Complete section and sign
Applicant's Action Complete section and sign
Decision Communicated Patient and Doctor are notified
Decision Timeframe 2-3 business days
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Doctor's office
Delivery Time Shipped next business day
Refill Process Good for 12 months
Limit Contact the program for details
Re-application New application every 12 months
   

Additional Information

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

Updated March 08, 2022


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

  • mogamulizumab-KPKC injection; iv (Poteligeo) Injection; IV
 

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 May 20, 2022