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Patient Assistance Information

 
4 Programs for Imbruvica capsule
 
 
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.
 
Imbruvica capsule
 
 
 
Johnson & Johnson Patient Assistance Foundation, Inc. Patient Assistance Program

PO Box 221857
Charlotte, NC 28222
Phone : (800)652-6227
Fax: (888)526-5168
Eligibility
> The Johnson & Johnson Patient Assistance Foundation, Inc. Patient Assistance Program provides brand name medications at no or low cost. Patients must have prescription coverage the needed medication. Some Medicare Part D patients who cannot afford their medicines, and who meet certain financial criteria, may also be eligible for assistance. Patient must permanently reside in the US or a US territory.
Who Can Apply
> Applications can be obtained by patients and doctors by calling or downloading from the link below.
Required
> Applications must be completed and signed by both the patient and doctor. Proof on income must also be attached. New application and documentation is needed every year.
Supply
> Not specified. Refill process varies by medication.
Ship To
> Doctor's office or a card will be sent to the patient to used at the pharmacy.
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.
 
Imbruvica capsule
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(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.
 
Imbruvica capsule
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
YOU&i Support Program


,
Phone : 877-877-3536
Fax: 800-752-5896
Eligibility
> Patients insurance status and income requirements will be considered on a case by case basis. Medicare Part D recipients are eligible. Patients must reside in the US.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. An application can also be downloaded.
Required
> Patients must enroll online or by phone. Doctors must complete a section of the application and sign. The application can then be faxed or mailed.
Supply
> Varies
Ship To
> Patient's home
Note
> Call for detailed information on the other programs offered: YOU&i Start Program: Eligible patients can receive up to a 30-day supply of Imbruvica free. YOU&i Access Instant Savings Program: Eligible patients pay no more than $10 per month for Imbruvica.
 
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.
 
Imbruvica capsule
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader