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Patient Assistance Information

 
2 Programs for Prialt injectable; intrathecal
 
 
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.
 
Prialt injectable; intrathecal
 
 
 
Prialt Navigator Reimbursement and Access Program


,
Phone : 855-774-2581
Fax: 855-774-2583
Eligibility
> The Prialt Navigator Reimbursement and Access Program is intended for patient that are uninsured or are underinsured. Medicare Part D patients are not eligible. Income requirements for this program have not been disclosed. Patients must be a US resident. Diagnosis and medical criteria have not been disclosed for this program.
Who Can Apply
> Doctor or doctor's office must call or download the application from the link below.
Required
> Application must be completed and signed by the doctor and the patient. Insurance information must be attached. The doctor will be notified within 2-3 days. The doctor must contact the company for refills. A new application and documentation are required every year.
Supply
> Up to a 90 day supply.
Ship To
> Medication will be shipped to the doctor's office.
Note
> Resources for HEALTHCARE PROFESSIONAL ONLY. The prescriber must enroll in the Navigator Program before enrolling patients.
 
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.
 
Prialt injectable; intrathecal
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
Download printable Form
(Requires Acrobat Reader