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Diplomat's Co-Pay Assistance Navigator Program
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Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
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(877)977-9118
Ext 89864
Fax:
(810)282-0176
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Eligibility
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Insurance determined case by case. Medicare Part D patients are eligible for this program. Income requirements determined case by case. Must be a US resident. Must have medically appropriate condition/diagnosis. |
| Who Can Apply
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Patient or Doctor may call to receive application via fax or mail. May also complete application online. Application is to be mailed or faxed back to company. |
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Required
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Doctor's action will be discussed with patient and Doctor after request is received. Patient must complete application, sign and provide annual income information. Proof of income may be requested by program at any time. Patient and/or Doctor are notified of decision within 1-2 business days. |
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Supply
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Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
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Ship To
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Once approved medication is shipped to Patient's home within 2 business days. |
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Note
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Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Zepatier |
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Merck Access Program for Zepatier
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PO Box 29067
Phoenix, AZ 85038
Phone
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866-251-6013
Fax:
800-803-3104
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Eligibility
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This program is intended for patients that have no prescription coverage for the needed medication. Medicare Part D recipients will be considered on an exception basis. Income requirements for this program have not been disclosed. Patients must have a medically appropriate diagnosis or condition. Patients must also reside in the US, be under the direct care of a licensed US physician and receive US health care services. |
| Who Can Apply
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Anyone interested can call or download an application. |
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Required
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Doctors must complete and sign the application. Patients must also complete and sign the application. Once complete, it can be faxed in. |
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Supply
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Not specified |
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Ship To
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Not specified |
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Note
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Zepatier |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
(Requires Acrobat Reader) 
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Merck Connect
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,
Phone
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800-489-5119
Fax:
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Eligibility
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This program is for healthcare professionals only. Patient eligibility will be determined on a case by case basis. Income requirements for this program have not been disclosed. The medication must be medically necessary as determined by a doctor. The patient must be treated by a US licensed healthcare professional. |
| Who Can Apply
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Patients can enroll online. |
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Required
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Doctors must enroll in the program. Patients must inform their doctor that they are in need. |
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Supply
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Up to a 30 day supply. |
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Ship To
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Not specified |
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Note
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Resources for HEALTHCARE PROFESSIONALS ONLY.
The Physician must register to access tools and materials for patient support, product sample requests, up-to-date professional resources, and other Merck professional sites. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Zepatier |
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
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(866)316-7263
Fax:
(866)316-7263
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Eligibility
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This is a copay assistance program for patients that have health insurance. The patient's insurance must cover the qualifying medication that they are seeking assistance for. Patient with Medicare Part D will be considered on a case by case basis. Patients must be at or below 400-500% of the federal poverty level, must have a medically appropriate diagnosis/condition and must reside and receive treatment in the US. |
| Who Can Apply
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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Patients must call for information or inform their doctor that they are in need. Doctors action will be discussed with the patient and doctor after the request is received. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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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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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Zepatier |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
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