Patient Assistance Information


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Patient Assistance Information

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4 Programs Sponsored By EMD Serono Inc. (External Link)


Connections for Growth Patient Assistance Program
PO Box 29023 Phoenix, AZ 85038 Phone : 800-582-7989 Fax: 877-408-4288
Eligibility
>	This program is for Patient's with no prescription coverage for needed medication. Medicare Part D patients are not eligible for this program. Income requirements for this program have not been disclosed. The patient must be a US citizen or legal resident and a child.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application is sent to Patient. Patient and Doctor will be notified of acceptance within 5-7 business days.
Required
>	The doctor must fill out a section and sign the application.The patient must fill out a section, sign the application and attach proof of income and any insurance information.
Supply
>	Up to 3 month supply. New Prescription required with each refill. Refill limit not specified. New application must be completed yearly.
Ship To
>	Medication is sent to Patient's home within 2 weeks.
Note
>	Doctor first needs to send statement of medical necessity form, and patient must first go through to the insurance verification program. Then an application will be sent out. The patient must also have been Stim tested in order to be eligible for this program.

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.
Saizen injection


Serostim Patient Assistance Program
PO Box 9535 Louisville, KY Phone : (877)714-2947 Ext opt.2 Fax: (800)214-8698
Eligibility
>	This program is intended for patients that are uninsured for needed medication. Medicare Part D patients are not eligible for this program. Income requirements for this program have not been disclosed. Must be US resident or legal alien.
Who Can Apply
>	Doctor/Doctor's office starts process by filling out Statement of Medical Necessity Form. Application is sent to Patient's home. Patient and Doctor will be notified in writing within 5-7 business days.
Required
>	Doctor must complete and fax Statement of Medical Necessity and signed Patient Authorization forms which are on the website. Patient must complete application, sign and attach a copy of proof of income.
Supply
>	Up to a 3 month supply. New prescription required for every refill. Refill limit not specified. New application must be completed every 6 months.
Ship To
>	Medication will be sent to Patient's home or Doctor's office within 2 weeks.
Note
>	Patients must first go through their insurance investigation process and must be referred by the AXIS Center case manager to the PAP. If they are referred to the PAP, they will receive an application to be completed. Serostim Copay Assistance Program: Good for up to 6 uses within a 12 month period: no more than once every 21 days. Company will cover up to $1,500 per month.

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.
Serostim injection


Saizen Easy Savings Program
, Phone : (800)582-7989 Fax: (877)408-4288
Eligibility
>	This program is intended for patients who may have insurance, but NOT have Medicaid. Medicare Part D patients are not eligible for this program. No income limits. MA residents are not eligible for this program.
Who Can Apply
>	The Doctor should call for an application or download it from the website. Application must be faxed back to company from Doctor's office. Patient and Doctor are notified of decision.
Required
>	Must have FDA approved diagnosis. Doctor must complete and fax Statement of Medical Necessity and signed Patient Authorization forms which are on the website. Patients just informs Doctor that he/she is in need.
Supply
>	Amount/supply varies. Refill process not applicable. Refill limit maximum of 12 times in one year. Re-application process not applicable.
Ship To
>	Shipping location not applicable.
Note
>	Patients must not have filled a Saizen prescription in the past 6 months. After program activation, patients can save up to $200 per month on monthly copay or coinsurance costs for 12 months. This program runs and renews on an annual basis.

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.
Saizen injection

Printable Application Forms Applications that patients can fill out and bring to their doctor.
Download printable Form Saizen Easy Savings Program
(Requires Acrobat Reader)


MS Lifelines
, Phone : (877)447-3243 Fax:
Eligibility
>	Insurance requirements determined case by case. Medicare part D eligibility varies. Income requirements for this program have not been disclosed. Must be a US resident.
Who Can Apply
>	Applicant must call for prescreening and application will be sent to the Patient via mail. Patient will be notified of decision within 7-10 business days.
Required
>	Must have MS. Doctor must fax in prescription. Patient must complete application, sign, attach proof of income and other requested documentation.
Supply
>	Amount/supply varies. Company contacts Patient to arrange refills. Refill limit not specified. New application and documentation required yearly.
Ship To
>	Medication will be shipped to Patient's home once approved. Shipped same day.
Note
>	Program does not use financial guidelines or an application for the first year of enrollment. They encourage patients to call the toll free number for assistance. Eligibility determined on a case-by-case basis.

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.
Rebif syringe; subcutaneous