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Afrezza Co-Pay Support Program
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,
Phone
:
866-991-2840
Fax:
855-834-3468
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Eligibility
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Patients must have no insurance and have a medically appropriate diagnosis/condition. |
| Who Can Apply
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Patient or healthcare providers can call to complete the application by phone or complete the application online. |
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Required
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Patients must call or enroll online. Doctors must provide a prescription. |
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Supply
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Not applicable |
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Ship To
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Patient is sent savings card to be used at pharmacy. |
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Note
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Afrezza® Patient Savings Card: Pay $0 for the first prescription. After that, pay no more than $30 for each prescription refill, depending on your insurance coverage.
With each prescription, receive 2 inhalers and a month’s supply of cartridges. |
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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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| Afrezza powder; inhalation |
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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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MyPraluent
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MyPRALUENT
1670 Century Center Parkway
Memphis, TN 38134
Phone
:
844-772-5836
Ext 1
Fax:
844-872-5447
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Eligibility
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Patients must be uninsured or underinsured. Income requirements for this program have not been disclosed. Patients must have a medically appropriate condition/diagnosis and must reside in the US, Puerto Rico or the USVI. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed to the doctor's office or they can download one. |
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Required
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Patients and doctors must each complete a section and sign the application. The application must then be faxed from the doctor's office. |
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Supply
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As prescribed by Doctor |
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Ship To
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Patient's home |
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Note
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Insurance benefits, claims assistance and/or other reimbursement help is offered.
This program also provides copay assistance.
Additional resources available, including a puncture-resistant sharps disposal container and a PRALUENT Travel Kit. |
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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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| Praluent |
| Praluent disposal container |
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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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Sanofi Patient Connection Program
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PO Box 222138
Charlotte, NC 28222
Phone
:
888-847-4877
Fax:
888-847-1797
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Eligibility
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Patients must have no prescription insurance and be ineligible for any state and federal programs. Medicare Part D recipients will be considered on an exception basis. Patients must be at or below 500% of FPL for oncology products and at or below 250% of FPL for all other products. Patients must also have a medically appropriate condition/diagnosis and have a social security number. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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Ship To
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Doctor's office |
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Note
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Negative decision may be appealed. Insurance benefits, claims assistance and/or other reimbursement help is offered. Exceptions to guidelines considered.
Patients who do not file taxes must either request a 4506-T form from the IRS, submit proof of benefits received (such as Social Security) Earning Statement, or submit W2's of the person who is supporting them financially.
Healthcare provider must contact the Program for REORDER FORMS.
*On most medications, excluding Lovenox, patients with Medicare Part D may be considered if they are not eligible for Low Income Subsidy, and they have spent at least 5% of annual household income on out-of-pocket costs for medications. |
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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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| Adacel injection |
| Apidra vial |
| Clolar (clofarabine) Injection |
| Elitek |
| Imogam |
| Imovax Rabies IM (Rabies Vaccine) |
| Jevtana |
| Lantus (insulin glargine [rDNA origin] injection) |
| Leukine (sargramostim) |
| Lovenox Injection |
| Menactra Meningococcal (Groups A, C, Y and W-135) Vaccine |
| Menomune A/C/Y/W-135 (meningococcal polysaccharide vaccine) |
| Mozobil (plerixafor injection) |
| Multaq (dronedarone) Tablets |
| Priftin (rifapentine) |
| Tenivac (tetanus and diphtheria toxoids adsorbed) |
| TheraCys BCG Live (Bacillus Calmette; Guerin) |
| Thymoglobulin |
| Toujeo Solostar injection |
| Zaltrap injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| (Requires Acrobat Reader)
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Synvisc Connection Personalized Reimbursement Solutions
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PO Box 222138
Charlotte, NC 28222
Phone
:
888-847-4877
Fax:
888-847-1797
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Eligibility
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Patients must be uninsured, be at or below 250% of the Federal Poverty Level, have osteoarthritis of the knee, be a US resident and have a social security number. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or download one. |
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Required
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Doctors must complete a section of the application and sign. Patients must complete a section of the application, sign and attach proof of income. |
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Supply
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Varies |
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Ship To
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Doctor's office |
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Note
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The doctor must only have two patients enrolled every six months.
Contact program for Spanish 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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| Synvisc syringe; prefilled |
| Synvisc-One syringe; prefilled |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
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