Don't qualify for this program? Visit the DBAs to look for financial assistance based on your diagnosis.  
Program 1 of 2.
Scroll down to see them all.
 

Banner Patient Support

This program provides brand name medications at no or low cost

Provided by: Banner Life Sciences Inc.


TEL: 855-322-6637


FAX: 866-539-0270
Languages Spoken:

English, Spanish, Others By Translation Service

Program Website

 

Program Applications and Forms

Banner Patient Support Enrollment Form (pages 1-3)

Banner Patient Support Enrollment Form Safety Information (pages 4 & 5)

Banner Patient Support Enrollment Form (pages 1-3) (Spanish)

Banner Patient Support Enrollment Form Safety Information (pages 4 & 5) (Spanish)

 

Medications

  • monomethyl fumarate capsule; delayed release (Bafiertam) Capsule; Delayed Release
 

Eligibility Requirements   

Insurance Status Determined case by case
Those with Part D Eligible? Not specified
Income Varies
Diagnosis/Medical Criteria Medically Necessary as determined by a Doctor
US Residency Required? Must be residing in the US or a US territory, and under the care of a US physician
   

Application

Obtaining Download from website
Receiving 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 Patient and Doctor are notified
Decision Timeframe Varies
   

Medication

Amount/Supply As prescribed by Doctor
Sent To Patient's home
Delivery Time Varies
Refill Process Pharmacy contacts patient
Limit Contact the program for details
Re-application Contact program for details.
   

Additional Information

Patient must sign the enrollment form to give the program permission to access their financial information in order to determine eligibility.

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

Updated May 09, 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

  • monomethyl fumarate capsule; delayed release (Bafiertam) Capsule; Delayed Release
 

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 April 25, 2022