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Torisel Reimbursement Support and Patient Assistance Program
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PO Box 220907
Charlotte, NC 28222
Phone
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866-993-8466
Fax:
866-993-8411
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Eligibility
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The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. The patient must also be under treatment from a US doctor. |
| Who Can Apply
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The doctor/doctor's office should call for an application. |
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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 of the enrollment form and sign it. |
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Supply
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Ship To
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Doctor's office |
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Note
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The doctor/doctor's office should 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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| Mylotarg |
| Neumega |
| Torisel Injection |
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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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Benefix Patient Assistance Program
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5870 Trinity Parkway
Suite 600
Centerville, VA 20120
Phone
:
888-999-2349
Ext OPT1, OPT2
Fax:
703-310-2524
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Eligibility
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The patient must have no insurance and have an income at or below $25,000 if single ($40,000 for a family). In cases of emergency, the company will send replacement after the medication was taken, but this is not normally a replacement program. |
| Who Can Apply
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The doctor/doctor's office should call for an application. |
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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 and sign the application. |
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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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The doctor/doctor's office should 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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| BeneFix |
| ReFacto (rAHF Factor VIII) |
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Wyeth Oncology Reimbursement Program
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Wyeth Oncology Reimbursement Program
Lash Group
San Bruno, CA 94066
Phone
:
(888) 638-6342
Fax:
(866) 836-0819
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Eligibility
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The patient must not have prescription coverage for the medication and have an income at or below 325% od the US Povertly Level. The patient must be under treatment from a US doctor. |
| Who Can Apply
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The doctor/doctor's office should call for an application. The application will be faxed out. The completed application must be mailed back. |
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Required
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The doctor must fill out a section, sign the application, and attach a prescription and a copy of the DEA or State License number. 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 is sent to the doctor's office. The doctor/doctor's office must contact the company to arrange refills. Once a year a new application with documentation is needed. |
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Ship To
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The medication is shipped to the doctor within 10 business days. Both the patient and doctor are notified in writing of acceptance or denial.
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Note
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The company also provides drug replacement if the insurance is denied and it is for an FDA-approved diagnosis. |
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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.
|
| Mylotarg |
| Neumega |
| |
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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