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Commitment to Care
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1250 Bayhill Dr
Suite 300
San Bruno, CA 94066
Phone
:
(800) 521-7157
Ext option 2
Fax:
(800) 683-7855
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Eligibility
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The patient cannot have prescription insurance, be ineligible for government programs and meet income guidelines that are not disclosed. This program is only for patients taking the medication for Hepatitis C.
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| Who Can Apply
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The patient must call for a prescreening. The application is sent to the patient's home. The completed application can be faxed or mailed back. The patient is notified of eligibility for the program. The estimated timeline for acceptance is 7-10 business days. The medication is usually shipped within 7-10 business days. |
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Required
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The doctor needs to provide a prescription to the patient. The patient must provide information and proof of income.
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Supply
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A 30-day supply is sent to the patient's home. |
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Ship To
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Physician's office or patient's home as indicated on application. |
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Note
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The patient must contact the company to arrange for refills. Every 6 months financial documentation is needed. |
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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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| Peg-Intron (peginterferon alfa-2b) |
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Commitment to Care for Hepatitis C Medications
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PO Box 18725
Louisville, KY 40261
Phone
:
800-521-7157
Ext OPT 2
Fax:
800-683-7855
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Eligibility
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| > |
The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. |
| Who Can Apply
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With the patient's permission, anyone concerned can call for an application. |
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Required
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| > |
The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
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Supply
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Up to a 30-day supply |
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Ship To
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| > |
Either Doctor's office or Patient's home |
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Note
|
| > |
With the patient's permission, anyone concerned can call for an application. |
| |
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.
|
| Peg-Intron (peginterferon alfa-2b) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
(Requires Acrobat Reader) 
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Commitment to Care for Oncology Medications
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6900 College Blvd
Suite 1000
Overland Park, KS 66211
Phone
:
800-521-7157
Ext OPT 1
Fax:
866-277-9328
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Eligibility
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| > |
The patient cannot have prescription insurance, be ineligible for any federal or state programs and meet income guidelines that are not disclosed. |
| Who Can Apply
|
| > |
With the patient's permission, anyone concerned can call for an application. |
|
Required
|
| > |
The doctor needs to provide a prescription to the patient.The patient must fill out a section, sign the application and attach proof of income and any insurance information. |
|
Supply
|
| > |
Up to a 30-day supply |
|
Ship To
|
| > |
Either Doctor's office or Patient's home |
|
Note
|
| > |
With the patient's permission, anyone concerned can call for an application. |
| |
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.
|
| Peg-Intron (peginterferon alfa-2b) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form Application Form |
| (Requires Acrobat Reader)
|
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|
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Patient Access Network Foundation (PAN)
|
PO Box 221858
Charlotte, NC 28222
Phone
:
(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. |
| |
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.
|
| Peg-Intron (peginterferon alfa-2b) |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
|
|