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Campath Distribution Program
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,
Phone
:
877-422-6728
Fax:
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Eligibility
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Insurance requirements for this program are not specified, this includes Medicare PartD. |
| Who Can Apply
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Doctor/Doctor's office must call to have application faxed to Doctor's office. Application must be faxed or mailed back to company from Doctor's office. |
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Required
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Doctor must complete section and sign. Patient must inform Doctor that he/she is in need. Doctor will be notified of decision. |
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Supply
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Amount/supply not specified. Refill process and limit not specified. Re-application process not applicable. |
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Ship To
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Not specified. |
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Note
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The Doctor must contact the program to place an order. |
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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.
| | Campath injection |
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Genzyme Co-Pay Assistance Program
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Genzyme Corporation
500 Kendall St.
Cambridge, MA 02142
Phone
:
(800)745-4447
Ext opt.3
Fax:
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Eligibility
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This program is intended for patients with no insurance. Medicare PartD not eligible for this program. Income limit not disclosed. Must be US citizen or legal entrant (Infusion costs are not covered in MA, MI, MN or RI). |
| Who Can Apply
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Call or complete online. Patient must complete online enrollment. Patient and Doctor or Specialty Pharmacy are notified within 7-10 business days. |
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Required
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Medically appropriate condition/diagnosis required. |
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Supply
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Amount/supply not applicable. Refill process not specified. Refill limit up to 1 year. Re-application process varies. |
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Ship To
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Not specified. |
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Note
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This program assists with out-of-pocket drug cost related to treatment with one of Genzyme's enzyme replacement therapies and certain infusion related costs:
Out-of-pocket costs such as drug and infusion related copays, co-insurance and deductibles are eligible for reimbursement.
Please visit a Genzyme product's website to complete the online application or call. |
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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.
| | Aldurazyme vial | | Cerdelga capsule | | Cerezyme injection | | Fabrazyme vial | | Lumizyme powder; iv | | Myozyme injectable; iv |
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MS One to One Patient Assistance Program
|
One to One Support Services
PO Box 220790
Charlotte, NC 28222
Phone
:
(855)676-6326
Fax:
(855)557-2478
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Eligibility
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Must be uninsured or rendered uninsured. Medicare PartD patients not eligible. Income must be at or below 500% of FPL. Must be US citizen or legal entrant. |
| Who Can Apply
|
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Call for application to be faxed or download from website. Application must be faxed back to company from Doctor's office. |
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Required
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Medically appropriate condition/diagnosis required. Doctor must complete section and sign. Patient must complete section, sign application and consent. Patient will be notified of decision. |
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Supply
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Amount/supply not specified. Refills are automatically sent out. Refill limit of 1 year. Company contacts patient about reapplying. |
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Ship To
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Ship to Patient's home. |
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Note
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Patient must have a US prescriber. |
| |
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.
| | Aubagio tablet | | Lemtrada |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form MS One to One Patient Assistance Program | (Requires Acrobat Reader) 
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Lemtrada REMS Program
|
,
Phone
:
(855)676-6326
Fax:
(855)557-2478
|
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Eligibility
|
| > |
Insurance requirements for this program are not specified. Medicare PartD eligibility not specified. Income requirements not disclosed. Must be US resident. |
| Who Can Apply
|
| > |
Call to have application faxed or download from website. Application must be faxed back to company from Doctor's office. Patient and Doctor are notified of decision. Decision timeframe varies. |
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Required
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Must have MS. Doctor must enroll in the program. Patient must inform Doctor that he/she is in need. |
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Supply
|
| > |
Amount/supply not specified. Refill process and limit not specified. Re-application process not specified. |
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Ship To
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| > |
Not specified. |
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Note
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Prescribing Physician, Healthcare Facilities, Pharmacies and Patients must enroll into the Risk Evaluation and Mitigation Strategy (REMS) Program prior to initiating the patient on treatment with LEMTRADA. Contact program for more detail. |
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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.
| | Lemtrada |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Lemtrada REMS Program | | (Requires Acrobat Reader)
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Renassist Patient Assistance Program (RPAP)
|
,
Phone
:
(800)847-0069
Ext opt.2
Fax:
(877)363-6732
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Eligibility
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| > |
Insurance requirements *See Additional Information section below
Those with Part D Eligible?*See Additional Information Section Below
Income requirements Vary. **See below for details |
| Who Can Apply
|
| > |
Call for application to be faxed, emailed, or mailed or download from website. Return application via email, fax or mail.
Must be a US citizen or possess a valid green card. |
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Required
|
| > |
Diagnosis/Medical Criteria not required. Doctor must complete section and sign. Patient must complete section, sign, attach required documents. Dialysis facility notified of acceptance or denial within 4 weeks. |
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Supply
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| > |
Up to 3 months supply. Refill form sent with each supply. Maximum of 3 refills through one year from date on original prescription. New application needed 1 year from date of prescription on original application. |
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Ship To
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Ship to Doctor's office or dialysis unit. |
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Note
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For the medication Renagel: Contact program for more information.
For the medication Hectorol: If on dialysis, the patient can not be receiving Medicare Part B.
For the medication Renvela: If the patient is Medicare eligible with income below 150% of the FPL, the patient must apply for the Limited Income Subsidy (LIS) and be denied. Proof of denial for LIS must be submitted along with the application.
Patients must meet AKF financial criteria. Patients can be in the 90-day waiting period for Medicare without drug coverage, ineligible for Medicare, or have Medicare with no prescription coverage. |
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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.
| | Hectorol injection | | Renagel tablet | | Renvela powder for oral suspension | | Renvela tablet |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
| | Download printable Form Renassist Patient Assistance Program (RPAP) | | (Requires Acrobat Reader)
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