| |
Diplomat's Co-Pay Assistance Navigator Program
|
Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
:
(877)977-9118
Ext 89864
Fax:
(810)282-0176
|
|
Eligibility
|
| > |
Insurance determined case by case. Medicare Part D patients are eligible for this program. Income requirements determined case by case. Must be a US resident. Must have medically appropriate condition/diagnosis. |
| Who Can Apply
|
| > |
Patient or Doctor may call to receive application via fax or mail. May also complete application online. Application is to be mailed or faxed back to company. |
|
Required
|
| > |
Doctor's action will be discussed with patient and Doctor after request is received. Patient must complete application, sign and provide annual income information. Proof of income may be requested by program at any time. Patient and/or Doctor are notified of decision within 1-2 business days. |
|
Supply
|
| > |
Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
|
Ship To
|
| > |
Once approved medication is shipped to Patient's home within 2 business days. |
|
Note
|
| > |
Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie |
| |
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.
|
| Sutent Capsule |
| |
| |
|
|
| |
Pfizer RxPathways Patient Assistance Program
|
PO Box 66585
St. Louis, MO 63166-6585
Phone
:
(866)706-2400
Fax:
(866)470-1748
|
|
Eligibility
|
| > |
The patient must either have no prescription coverage, or not enough coverage, to pay for their prescribed Pfizer medicine(s). Income requirements for this program have not been disclosed. Patients must reside in the US, Puerto Rico or USVI. |
| Who Can Apply
|
| > |
Anyone who has been prescribed a Pfizer medicine and is in need of assistance can call or download an application. |
|
Required
|
| > |
The doctor must fill out a section and sign. The patient must fill out a section, sign the application and attach proof of income. |
|
Supply
|
| > |
Varies |
|
Ship To
|
| > |
Varies |
|
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.
|
| Sutent Capsule |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| Download printable Form |
| Download printable Form |
| Download printable Form |
| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|