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SP-Cares
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PO Box 52122
Phoenix, AZ 85072
Phone
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800-656-9485
Ext OPT 1
Fax:
800-995-9620
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Eligibility
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The patient must have no prescription coverage for the requested medication and have an income at or below 250% of the Federal Poverty Level. |
| Who Can Apply
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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Required
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The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income. |
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Supply
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Up to a 90-day supply |
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Ship To
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Doctor's office |
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Note
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Anyone requesting assistance can call to request a faxed application or download it from the website. |
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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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| Asmanex Twisthaler Inhalation Powder |
| Avelox Tablets |
| Cipro XR Tablets |
| Diprolene Lotion (betamethasone dipropionate) |
| Diprolene Ointment (betamethasone dipropionate) |
| Elocon Cream (mometasone furoate) |
| Elocon Lotion (mometasone furoate) |
| Elocon Ointment (mometasone furoate) |
| Foradil Powder for Inhalation |
| K-Dur Tablets |
| Lotrisone Cream |
| Lotrisone Lotion |
| Nasonex Nasal Spray |
| Nitro-Dur Patch |
| Proventil HFA Inhaler |
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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 Application Form |
(Requires Acrobat Reader) 
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Commitment to Care for Oncology Medications
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6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone
:
800-521-7157
Ext OPT 1
Fax:
866-277-9328
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. |
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Required
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The doctor needs to provide a prescription to the patient.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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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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Either Doctor's office or Patient's home |
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Note
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With the patient's permission, anyone concerned can call for an application. |
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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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| Intron-A Powder for Injection |
| Intron-A Solution for Injection |
| Noxafil Oral Suspension |
| Peg-Intron (peginterferon alfa-2b) |
| Temodar (temozolomide) |
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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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Commitment to Care for Hepatitis C Medications
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PO Box 18725
Louisville, KY 40261
Phone
:
800-521-7157
Ext OPT 2
Fax:
800-683-7855
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Eligibility
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The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. |
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Required
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The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
|
Supply
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Up to a 30-day supply |
|
Ship To
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| > |
Either Doctor's office or Patient's home |
|
Note
|
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With the patient's permission, anyone concerned can call for an application. |
| |
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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| Intron-A Injection |
| Peg-Intron (peginterferon alfa-2b) |
| Rebetol (ribavirin) |
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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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Schering Laboratories Patient Assistance Program
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PO Box 6842
Somerset, NJ 08875
Phone
:
800-656-9485
Ext OPT2
Fax:
Not Applicable
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Eligibility
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The patient must have no prescription coverage for any medications and have an income at or below 200% of the Federal Poverty Level. This is a hospital replacement program, so the patient must have already received the medication.The patient must also be a US resident. |
| Who Can Apply
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Someone from the hospital must call for an application. |
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Required
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The hospital contact person must fill out and sign the application.The patient must provide information (financial, insurance, and medical) but no signature is required. |
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Supply
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Ship To
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Hospital |
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Note
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Someone from the hospital must call for an application. |
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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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| Adalat Tablets |
| Asmanex Twisthaler Inhalation Powder |
| Avelox IV |
| Avelox Tablets |
| Biltricide (praziquantel) |
| Cipro I.V. (ciprofloxacin) |
| Cipro XR Tablets |
| Diprolene Lotion (betamethasone dipropionate) |
| Diprolene Ointment (betamethasone dipropionate) |
| Dome Paste Bandages |
| Elocon Cream (mometasone furoate) |
| Elocon Ointment (mometasone furoate) |
| Foradil Powder for Inhalation |
| Integrilin (eptifibatide) |
| Integrilin Infusion Vial Injection |
| K-Dur Tablets |
| Lotrisone Cream |
| Lotrisone Lotion |
| Nasonex Nasal Spray |
| Nitro-Dur Patch |
| Proventil HFA Inhaler |
| Proventil Ud Solution |
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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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Commitment to Care
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1250 Bayhill Dr
Suite 300
San Bruno, CA 94066
Phone
:
(800) 521-7157
Ext option 2
Fax:
(800) 683-7855
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Eligibility
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The patient cannot have prescription insurance, be ineligible for government programs and meet income guidelines that are not disclosed. This program is only for patients taking the medication for Hepatitis C.
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| Who Can Apply
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The patient must call for a prescreening. The application is sent to the patient's home. The completed application can be faxed or mailed back. The patient is notified of eligibility for the program. The estimated timeline for acceptance is 7-10 business days. The medication is usually shipped within 7-10 business days. |
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Required
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The doctor needs to provide a prescription to the patient. The patient must provide information and proof of income.
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Supply
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A 30-day supply is sent to the patient's home. |
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Ship To
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Physician's office or patient's home as indicated on application. |
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Note
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The patient must contact the company to arrange for refills. Every 6 months financial documentation is needed. |
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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.
|
| Intron A (interferon alfa-2b recombinant) |
| Peg-Intron (peginterferon alfa-2b) |
| Rebetol (ribavirin) |
| Temodar (temozolomide) |
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