Registered Users Log-in:

E-mail Address:
 

Password:
 

  
Forgot Password?
Registration
 
Patient Assistance Information

 
Program Sponsored By Patient Access Network Foundation (External Link)
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> 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
> Patients or healthcare providers can complete the application online or by phone.
Required
> 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.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *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.
 
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.
 
Abraxane injection
Absorica capsule
Accolate
Accuneb
Accupril tablet
Accuretic tablet
Aceon
Aclovate
Actemra
Acthrel
Actimmune
Actonel tablet
Adcetris
Adriamycin
Adrucil
Advair Diskus
Advair HFA
Afinitor
Afinitor Disperz tablet
Agrylin
A-Hydrocort
AK-Pentolate
Aldactazide tablet
Aldactone tablet
Aldara
Alecensa
Alimta
Alkeran
Alora
Alphatrex
Altace capsule
Altoprev tablet; extended release
A-Methapred
Amidate
Amnesteem
Ampyra
Anaprox tablet
Androxy
Ansaid tablet
Antara capsule
Apexicon
ApexiCon E
Apligraf
Apokyn
Apriso
Aptivus
Aranesp
Arava
Aredia
Arimidex
Arnuity Ellipta powder; inhalation
Aromasin
Arthrotec
Arzerra
Asacol
Asacol HD tablet; delayed release
Asmalpred
Asmanex
Asmanex HFA
Asmanex Twisthaler
Astagraf XL capsule; extended release
Atacand
Atacand HCT tablet
Atelvia tablet; delayed release
Atgam
Atripla
Atrovent HFA
Aubagio
Auryxia
Avalide tablet
Avapro tablet
Avastin
Avonex
Azasan
Azilect
Azulfidine
Bactroban
Beleodaq
Bendeka
Benicar HCT Tablets
Benicar Tablets
Betapace
Betaseron
Bicnu
BiDil tablet
Binosto
BioVance
Bivigam liquid
Blephamide
Blephamide S.O.P.
Blocadren
Boniva
Bosulif
Breo Ellipta
Brethine
Brevibloc
Bumex
Bystolic Tablets
Caduet tablet
Calan
Calcitrene
Cambia oral solution
Campath
Camptosar
Canasa
Capex
Capoten tablet
Caprelsa
Carac
Cardizem
Cardizem LA Tablets
Carimune NF Injection
Carmol HC
Cartia XT
Casodex
Cataflam
CeeNU
Celebrex
Celestone
Cellcept
Cenestin tablet
Cerdelga
Ceredase
Cerezyme injection
Cerubidine
Chemet
Cimzia
Claravis
Climara
Clinoril tablet
Clobeta
Clobex
Clodan
Cloderm cream
Cogentin
Colazal
Colestid
Combivent
Combivent Respimat
Combivir
Cometriq
Complera
Comtan
Copaxone
Copegus
Cordarone
Cordran
Coreg CR Tablets
Coreg tablet
Corgard tablet
Cormax
Cortalo
Cortef
Cortisporin
Cortone
Corvert injection
Corzide
Cosentyx
Cotellic
Covera HS
Cozaar
Crestor
Crixivan
Cuprimine
Cutivate
Cyclogyl
Cyramza
Cytoxan
Dacogen injection (decitabine)
Daklinza
Danocrine (danazol)
Darzalex
Daypro
Decadron (Dexamethasone)
DELESTROGEN (estradiol valerate)
Delzicol
Depen (penicillamine)
Depo-Medrol Injection
Dermagraft dermal substitute
Derma-Smoothe
Dermasorb TA
Dermatop Emollient Cream (prednicarbate emollient)
DermOtic Oil Ear Drop oil ear drops; otic
Desferal Injection (deferoxamine mesylae USP)
Desonate gel
Desowen (desonide)
DexPak
Digox
Dilacor XR Capsule
Dilatrate-SR (Isosorbide Dinitrate)
Dilt-CD
Dilt-XR capsule; extended release
Diltzac
Diovan HCT Tablets
Diovan Tablets
Dipentum (olsalazine sodium capsules)
Diuril (Chlorothiazide)
Divigel gel
Docefrez
Dovonex
Doxil Injection
Droxia Capsules 200mg, 300mg, 400mg (hydroxyurea)
Duavee
DUEXIS
Dulera aerosol; inhalation
Duopa
Durezol ophthalmic emulsion
Dutoprol tablet; extended release
Dyazide capsule
Dyrenium capsule
EC-Naprosyn (naproxen)
Edarbi tablet
Edarbyclor tablet
Edurant tablet
Efudex (fluorouracil)
Eldepryl Capsules
Elelyso
Elestrin gel
Eligard
Eliphos
Elixophyllin
Ellence
Eloxatin
Empliciti
Enbrel (etanercept)
Enjuvia Tablets
Enstilar
Entocort EC
Entresto tablet
Entyvio
Epaned oral solution
EpiFix
Epivir Tablets
Epivir-HBV Tablets
Epogen (epoetin alfa)
Epzicom Tablets
Erbitux Injection 50ml, 100ml (cetuximab)
Erivedge
Erwinaze injection
ESTRACE (estradiol vaginal cream)
Estraderm (estradiol transdermal sstem)
Estrasorb emulsion; topical
EstroGel
Etopophos Injection 100mg (etoposide phosphate)
Eulexin (flutamide)
Evamist spray
Evista Tablets
Evotaz
Exelon Capsules
Exjade (deferasirox)
Extavia
Eylea
Fareston Tablets
Farydak capsule
Faslodex Injection
Femara Tablets (letrozole)
Femtrace
Fenoglide tablet
Ferriprox
Fibricor tablet
Firmagon
Flarex Suspension
Flebogamma DIF
Flector Patch patch
Flonase
Flo-Pred
Flovent Diskus
Flovent HFA Inhalation Aerosol
Fludara
Fluor-Op
Fluoroplex
FML (fluorometholone ophthalmic ointment)
FML-Forte
Folotyn
Foradil Aerolizer
Fortaderm
Fortaderm Antimicrobial
Forteo Injection
Fortical
Fosamax Plus D Tablets
Fosamax Tablets
Fosrenol
Fusilev
Fuzeon
Galzin (zinc acetate)
Gammagard
Gammagard Liquid
Gammaked
Gammaplex iv
Gamunex
Gamunex-C
Gattex
Gazyva
Gilenya capsule
Gilotrif
Glatopa
Gleevac Capsules (imatinib mesylate)
Gleostine
Grafix CORE
Grafix PRIME
Granix
Halaven
Halog
Harvoni
Hecoria
Hectorol
Hemangeol
Hexalen (altretamine)
Humira Injection
Hycamtin capsule
Hydrea (Hydroxyurea)
Hyzaar Tablets
Ibrance
Iclusig
Ifex (ifosfamide)
Iluvien implant
Imbruvica capsule
Imuran (azathioprine)
Incivek
Inderide Tablets
Indocin
Infergen (interferon alfacon-1interferon)
Inlyta Tablets
InnoPran XL
Inspra Tablets
Intelence Tablet
Intron A (interferon alfa-2b recombinant)
Invirase Capsules
Iressa
Isentress
Isordil
Istodax injection
Ixempra IV 15mg, 45mg (ixabepilone)
Jadenu
Jakafi tablet
Jevtana
Juxtapid
Kadcyla
Kaletra
Kayexalate Powder
Kenalog
Keytruda
Kineret
Kionex (sodium polystyrene sulfonate)
Korlym tablet
Kynamro
Lemtrada
Lenvima
Lescol Capsules
Leukeran Tablets
Leukine (sargramostim)
Leustatin Injection
Levo-T
Levothroid (levothyroxine sodium tablets, USP)
Levulan Kerastick (aminolevulinic acid HCl)
Lexiva
Lialda
Lipofen capsule
Liptruzet tablet
Locoid® Lotion
Lodosyn Tablets
Lofibra (Micronized) capsule
Lonsurf
Lopressor HCT
Lopressor tablet
Lucentis Injection
Lufyllin (dyphylline)
Lupron Depot
Lynparza
Lysodren Tablets 500mg (mitotane)
Macugen
Matulane (procarbazine HCL)
Matzim
Mavik tablet
Maxitrol Suspension
Maxzide tablet
Megace (Megestrol Acetate)
Mekinist tablet
Menest (esterified estrogen)
Menostar
Mesnex (mesna)
Metastron
Metopirone (metyrapone)
Miacalcin
Micardis
Micardis HCT
Midamor (Amiloride HCl)
Mifeprex (mifepristone)
Millipred
Mirapex
Mirapex Extended Release Tablets
MODERIBA (ribavirin)
Momexin
Monopril tablet
Monopril-HCT (fosinpril sodium; hydrochlorothiazide)
Mozobil (plerixafor injection)
Multaq (dronedarone) Tablets
Mustargen (mechlorethamine HCl)
Myorisan
Nalfon (Fenoprofen Calcium)
Naprelan (Naproxen Sodium)
Navelbine (vinorelbine tartrate)
Neo-Polycin
Neoral
Neupogen (filgrastim)
Neupro
Nexavar
Nexterone
Niacor (Niacin)
Niaspan ER Tablets
Nilandron
Ninlaro
Nipent (pentostatin)
Nizoral Tablets
Nolvadex Tablets
Norpace Capsules
Norpace CR Capsules
Norvir
Novantrone (mitoxantrone HCI)
Vial 250 mcg, 500 mcg (romiplostim)
Nucala
Nucort
Nuzon
Oasis
Oasis Tri-Layer
Octagam
Odefsey
Odomzo capsule
Olux ® Foam 0.05%
Olysio capsule
Omnipred
Oncaspar vial
Opdivo
Orapred (prednisolone sodium phospate)
Orencia Injection 250mg/ml (abatacept)
Otezla tablet
Otrexup
Oxsoralen
Ozurdex
Pacerone (Amiodarone HCl)
Pandel (hydrocortisone probutate)
Paraplatin (carboplatin)
Parcopa Tablets
Parlodel (Bromocriptine Mesylate)
Pediaderm HC
Pediaderm TA
Pediapred (prednisolone sodium phospate)
Pegasys Injection
Pegasys ProClick auto-injector
Peg-Intron (peginterferon alfa-2b)
Pennsaid
PENTASA (mesalamine) 250mg controlled-release capsules
Perforomist
Periactin (cyprohetadine HCL)
Perjeta
Phoslo
Phoslyra oral solution
Photofrin (porfimer sodium)
Plaquenil
Platinol
Plegridy
Poly-Dex
Poly-Pred
Pomalyst capsule
Portrazza
Praluent
Pred Mild
Pred-G
Prelone
Premarin
Prevalite (Cholestyramine)
Prezcobix tablet
Prezista Tablets
Prinzide (lisinopril; hydrochlorothiazide)
Privigen vial; single-use
Proair HFA Inhaler
Proair Respiclick powder; inhalation
Procrit Solution
proglycem
Prograf (tacrolimus)
Proleukin (aldesleukin for injection)
Promacta
Pronestyl
Provenge
Proventil
Proventil HFA
Psorcon
Pulmicort (budesonide)
Pulmicort Flexhaler
Quadramet
Questran (Cholestyramine)
Qvar (beclomethasone dipropionate)
Rapamune
Rasuvo injection
RAYOS
Rebetol (ribavirin)
Rebif
Reclast
REGRANEX® Gel
Relafen (nabumetone)
Remicade (infliximab)
Renagel
Renvela
Repatha Sureclick auto-injector; pre-filled
Requip Tablets
Rescriptor Tablets
Retisert
Retrovir Capsules
Revlimid
Rexaphenac
Reyataz capsules 100mg, 150mg, 200mg, 300mg (atazanavir sulfate)
Ribasphere RibaPak
Ribasphere Tablets
Ribatab
Ridaura (auranofin)
Rocaltrol (calcitrol)
Rowasa (mesalamine)
Rytary capsule; extended release
Rythmol SR (propafenone HCl)
Sabril
Sandimmune
Sandostatin
Sandostatin LAR
Scalacort
Selzentry Tablets
Serevent
Sfrowasa
Signifor
Signifor LAR
Simcor
Simponi
Simponi Aria
Sinemet CR Tablets
Sinemet Tablets (carbidopa; levodopa)
Singulair
Soltamox
Solu-Cortef Sterile Powder for Injection
Solu-Medrol (methylprednisolone sodium succinate)
Somatuline Depot injection
Soriatane
Sorilux aerosol; foam
Sorine tablet
Sotret
Sotylize oral solution
Sovaldi
Spiriva HandiHaler
Spiriva Respimat spray
Sprycel Tablets 20mg, 50mg, 70mg (dasatinib)
Sps
Stalevo
Stelara injection
Stiolto Respimat spray
Stivarga
Stribild
Sulfazine
Sustiva
Sutent Capsules
Sylatron syringe
Symbicort
Symmetrel (Amantadine Hydrochloride)
Synagis (palivizumab)
Synalar (fluocinolone acetonide)
Synribo
Synthroid
Syprine
Taclonex suspension; topical
Tafinlar capsule
Tambocor Tablets (flecainide acetate)
Targretin
Tasigna capsule
Tasmar Tablets
Taxol
Taxotere
Tazorac
Taztia
Tecfidera
Technivie tablet
Temodar (temozolomide)
Temovate (clobetasol propionate)
Tenoretic 100 tablet
Teveten HCT Tablets
Teveten Tablets
Thalomid (thalidomide)
Theo-24 (theophylline)
Theochron (theophylline)
TheraCys BCG Live (Bacillus Calmette; Guerin)
Thymoglobulin
Thyrogen (thyrotropin alfa)
Tice BCG (BCG Live)
Tikosyn Tablets (dofetilide)
Tirosint
Tivicay
Tivorbex capsule
Topicort (desoximetasone)
Toposar (Etoposide)
Toprol-XL (metoprolol succinate) Extended Release Tablets
Torisel Injection
Treanda
Trelstar
Tricor Tablets
Triderm
Triesence
Triglide Tablets
TRILIPIX
Trizivir Tablets
Tybost
Tykerb
Tysabri
Uceris
U-Cort
Ultravate Topical Ointment
Uniretic (moexipril HCl; hydrochlorothiazide)
Univasc (moexipril HCl)
Valchlor
Vanos cream; 0.1%
Vantas Implant
Vectical
Velban (Vinblastine Sulfate)
Velcade
Velphoro
Veltassa
Ventolin HFA Inhaler
VePesid (Etoposide)
Verdeso
Verelan (verapamil HCl)
Veripred
Vexol Suspension
Victrelis
Vidaza
Videx (didanosine)
Viekira Pak
Vimovo delayed-release tablets
Vincasar PFS Injection
Viracept
Viramune
VIRAMUNE XR (nevirapine)
Visudyne
Vitekta tablet
Vivaglobin Subcutaneous
Vivelle Dot (Estradiol)
Voltaren Ophthalmic Solution
Voltaren XR (Diclofenac Sodium)
Vospire ER
Votrient tablet
VPRIV
Vytorin tablet
Westcort (hydrocortisone velerate)
Xalkori Capsules
Xeljanz
Xeloda Tablets
Xerese cream; topical
XGEVA (denosumab)
Xifaxan Tablets
Xofigo
Xopenex
Xopenex HFA
Xtandi
Yervoy Injection
Zaltrap (ziv-aflibercept)
Zanaflex (tizanidine HCl)
Zanosar (streptozocin)
Zaroxolyn (metolazone)
Zarxio injection
Zavesca
Zebeta (bisoprolol fumarate)
Zelapar
Zelboraf
Zemplar
Zenatane
Zepatier
Zerit (stavudine)
Zestril (lisinopril)
Zetia Tablets
Ziagen
Zipsor
Zithranol Shampoo shampoo
Zithranol-RR encapsulated cream
Zoladex
Zolinza Capsules
Zometa
Zorbtive
Zortress tablet
Zorvolex
Zydelig
Zyflo
Zyflo CR
Zykadia capsule
Zylet Ophthalmic Suspension
Zytiga tablet
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader