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Patient Assistance Information

 
3 Programs Sponsored By Chiesi USA Inc. (External Link)
 
 
Chiesi CAREDIRECT (Bethkis, Pertzye)

Chiesi CareDirect Patient Assistance Program
PO Box 30317
Bethesda, MD 20824
Phone : 888-865-1222
Fax: 866-410-6241
Eligibility
> This program is intended for patients that are uninsured or are underinsured with no prescription coverage and are a US citizen or legal entrant. Medicare Part D patients are not eligible for this program. Must provide diagnosis code. Income must be at or below 400% of FPL.
Who Can Apply
> Doctors and Patients can call to request an application via fax, email or download one from the website. The application may be returned via fax or mail.
Required
> Doctors and patients must complete and sign the application. Patient must attach proof of income and other requested documentation. Patient and Doctor are notified within 1-2 business days.
Supply
> Amount supplied as prescribed by Doctor
Ship To
> Medication is shipped to Patient's home. Refills are automatically sent out and the Patient must submit a new application every 12 months.
Note
> This program was formerly known as Cornerstone CAREDIRECT. The program also includes copay assistance and a nutritional rebate program. The nutritional rebate program is for Pertzye patients only.
 
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.
 
Bethkis solution; inhalation
Pertzye capsule; delayed release
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Chiesi CareDirect PAP
(Requires Acrobat Reader
 
 
Zyflo Connect Patient Assistance Program


,
Phone : 844-699-9356
Fax:
Eligibility
> Uninsured or Underinsured with no prescription coverage. Medicare part D eligibility is determined case by case. Income requirements for this program have not been disclosed. Patient must be a US citizen or legal entrant.
Who Can Apply
> Doctor/Doctor's office must call to request application, which will be sent to the Doctor's office and must be faxed back from the Doctor's office. No online application available.
Required
> Doctor must complete section and sign. Patient must complete section, sign, attach proof of income and other requested documentation. Patient and Doctor will be notified of acceptance.
Supply
> Amount/supply not specified.
Ship To
> Medication will be shipped to Patient's home in 1-2 business days. Refills are automatically sent out and patient must complete a new application every 12 months.
Note
> Resources for HEALTHCARE PROFESSIONALS ONLY. Physician must call to obtain an enrollment form.
 
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.
 
Zyflo CR tablet; extended release
 
 
 
Zyflo Connect Co-Pay Program


,
Phone : 844-699-9356
Fax:
Eligibility
> This program is intended for patients that are uninsured or are underinsured. Medicare Part D patients are not eligible for this program. Patients must be a US resident or resident of Puerto Rico. Income requirements for this program have not been disclosed.
Who Can Apply
> Patient must call to enroll once Doctor gives them the prescription. No online application available.
Required
>
Supply
> 30 day supply. Refill limit, refill process and re-application not specified.
Ship To
> Medication will be sent to Patient's home.
Note
> Out-of-pocket benefit equals an amount up to $2,500 per month with a maximum benefit of $30,000 per year. If a patient exceeds the maximum monthly benefit of $2,500, the patient will be responsible for the outstanding balance. This program expires December 31, 2016
 
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.
 
Zyflo CR tablet; extended release