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Diplomat's Co-Pay Assistance Navigator Program
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Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
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(877)977-9118
Ext 89864
Fax:
(810)282-0176
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Eligibility
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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
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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. |
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Required
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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. |
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Supply
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Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
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Ship To
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Once approved medication is shipped to Patient's home within 2 business days. |
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Note
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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 |
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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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| Temodar capsule |
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Merck Patient Assistance Program
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PO Box 690
Horsham, PA 19044
Phone
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800-727-5400
Fax:
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Eligibility
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This program provides brand name medications at no or low cost. Patient eligibility will be determined in a case by case basis. Medicare Part D recipients are eligible. Patients must be at or below 400% of the federal poverty level. Patients must be a US resident. |
| Who Can Apply
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Anyone interested can call or download the application. |
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Required
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Doctors and patients must complete and sign the application. The original application must be mailed NOT faxed. A new application is needed yearly. |
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Supply
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90 day supply with up to 3 refills, for a total of up to 1 year of medications. Patients can request refills via a toll-free number. |
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Ship To
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Doctor's office or patient's home |
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Note
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At Merck we realize that sometimes exceptions need to be made based on the patient's individual circumstances. Individuals who do not meet the insurance criteria may still qualify for the Merck Patient Assistance Program if they attest that they have special circumstances of financial hardship, and their income meets the program criteria.
*The Enrollment Form must be mailed. Please do not fax. |
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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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| Temodar capsule |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form |
| Download printable Form |
(Requires Acrobat Reader) 
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