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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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| Lialda |
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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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Shire Cares
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Shire Cares Patient Assistance & Support Program
PO Box 5666
Louisville, KY 40255
Phone
:
888-227-3755
Fax:
877-922-7379
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Eligibility
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Patients insurance status will be considered on a case by case basis. Medicare Part D recipients are eligible. Patients must be at or below 300% of the Federal Poverty Level, must have an FDA-approved diagnosis and must be a US citizen or legal entrant. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed, mailed or it can be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section, sign, attach proof of income and attach any insurance information. |
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Supply
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Not specified |
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Ship To
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Patient is sent a card to be used at the pharmacy. |
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Note
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Each Application will be considered on a case by case basis. |
| |
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.
|
| Lialda |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| (Requires Acrobat Reader)
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