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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
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(866)316-7263
Fax:
(866)316-7263
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Eligibility
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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
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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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. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*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. |
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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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| 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® (hydrocortisone butyrate) 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® (fluocinolone acetonide intravitreal implant) |
| 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® (rifaximin) 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® (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) |
| Zytiga tablet |
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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 |
(Requires Acrobat Reader) 
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