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Patient Assistance Information

 
4 Programs for Revlimid
 
 
Celgene Co-Pay Assistance Program

Celgene Corporation
86 Morris Avenue
Summit, NJ 07901
Phone : 800-931-8691
Fax: (800) 822-2496
Eligibility
> This program is intended for patients that have private insurance with a gross annual household income at or below $100,000 and are a US resident. Medicare Part D patients are not eligible for this program.
Who Can Apply
> Applicant must call for prescreening. Patient is then contacted if eligible after phone screening & will be contacted for any additional information. Patient and Doctor are notified within 24-48hrs of decision.
Required
>
Supply
> Supply and Refill process not applicable at this time. Re-application process not specified.
Ship To
> Not specified.
Note
> Please visit www.celgenepatientsupport.com for more information. No online application available.
 
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.
 
Revlimid
 
 
 
Celgene Patient Support

Celgene Corporation
Summit, NJ 07901
Phone : 800-931-8691
Fax: 800-822-2496
Eligibility
> This program is intended for patients that may have insurance, this includes Medicare Part D patients. Income requirements for this program have not been disclosed. Patient must be a US resident with prescription from US doctor.
Who Can Apply
> Anyone requesting assistance can call to request an application to me mailed, faxed or download it from the website. Application needs to be returned via fax or mail.
Required
> The doctor must complete section and sign the application. The patient must complete section, sign, attach proof of income and any insurance information. Patient and Doctor will be notified of acceptance within 24-48 hours.
Supply
> Up to 1 month supply. Patient or Doctor must contact company for refills. Company will contact patient about reapplying.
Ship To
> Doctor's office or patient's home.
Note
>
 
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.
 
Revlimid
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Celgene Patient Assistance Application
(Requires Acrobat Reader
 
 
Good Days Program

6900 dallas Parkway
Suite 200
Plano, TX 75024
Phone : (877)968-7233
Fax: (214)570-3621
Eligibility
> Insurance requirements not specified, this includes Medicare PartD. Income requirements for this program have not been disclosed. US residency requirements not specified.
Who Can Apply
> Call to have application faxed, mailed, download from website or apply online. Return application via fax, mail or submit online. Patient and/or Doctor are notified of decision.
Required
> Diagnosis/Medical Criteria not specified. Doctor gives prescription to patient. Patient must complete application, sign and attach required documents.
Supply
> Refill process and limit not specified. Must re-enroll at the end of every calendar year.
Ship To
> Shipping location not specified.
Note
> 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.
 
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.
 
Revlimid
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Good Days Program
(Requires Acrobat Reader
 
 
Patient Access Network Foundation (PAN)

PO Box 221858
Charlotte, NC 28222
Phone : (866)316-7263
Fax: (866)316-7263
Eligibility
> 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
> Patients or healthcare providers can complete the application online or by phone.
Required
> 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.
Supply
> Not applicable
Ship To
> Patient sent card to be used at pharmacy
Note
> *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.
 
Revlimid
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader