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Berlex Laboratories Patient Assistance Program
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Berlex Patient Assistance Program
PO Box 1000 M2/1-5
Montville, NJ 07045
Phone
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(888) 237-5394
Ext 6, 1
Fax:
(973) 305-3545
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Eligibility
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To be accepted into the Berlex Patient Assistance Program, a patient must meet the following criteria: 1) Must be a US citizen 2) Must be ineligible for any public or private health insurance, including Medicare and Medicaid and any other state or private programs and have an annual gross family income of $20,000 or less. (Annual Gross Family Income includes salary, Social Security, disability payments, pension benefits, unemployment, etc. and must include spouse's income if married) or 3) Be eligible for Medicare but ineligible for prescription coverage and must have an annual gross family income of $15,000 or less; and 4) must be under the care of a doctor/prescriber who has prescribed Betapace, Betapace AF, or Climara as medically appropriate for the patient applying for assistance. |
| Who Can Apply
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Doctor/prescriber's office should call the number above and use option 6, option 1, between 9 a.m. and 5 p.m. EST. |
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Required
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Income and insurance information are required on the application. |
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Supply
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Three month supply (Betapace AF is shipped in bottles of 60) |
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Ship To
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Physician's office |
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Note
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If the patient is eligible, they will receive up to a three-month supply of medication usually within a week to 10 days. After a year, patient must reapply.
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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.
| | Betapace AF Tablets | | Climara transdermal |
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Berlex Oncology CamCare Program
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Berlex Oncology CamCare Program
PO Box 221289
Charlotte, NC 28222-1289
Phone
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(800) 473-5832
Fax:
(800) 513-1824
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Eligibility
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Patient must be physicially residing in the US or its territories and must be ineligible for third party prescription coverage. |
| Who Can Apply
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Anyone may call to initiate application process.
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Required
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Completed application with original signatures is required. |
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Supply
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As requested by physician. |
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Ship To
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Physician's office. |
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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.
| | Campath | | Fludara (fludarabine phosphate) | | Leukine (sargramostim) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Application Form | (Requires Acrobat Reader) 
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The Betaseron Foundation
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The Betaseron Foundation
PO Box 221349
Charlotte, NC 28222-1349
Phone
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(800) 948-5777
Fax:
(877) 744-5615
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Eligibility
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Patients must have a confirmed diagnosis of multiple sclerosis and be U.S. residents. |
| Who Can Apply
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Anyone may call to initiate application process.
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Required
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Patients and their prescribing physicians must submit a completed application, and income verification is required. A copy of the most recent federal tax return is preferred, with verification of any Social Security benefits received. |
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Supply
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As indicated by physician. |
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Ship To
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Physician's office. |
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Note
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Program participants are required to pay a program participation fee for the Betaseron provided through the foundation. Eligibility for continuation in the program will be verified periodically, and all applications must be renewed annually. |
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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.
| | Betaseron (interferon beta-1b) |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Application Form | | (Requires Acrobat Reader)
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