| |
Dermagraft Support Program (Shire RM Cares)
|
,
Phone
:
800-444-7125
Fax:
877-337-6247
|
|
Eligibility
|
| > |
Patients must be uninsured or unable to afford treatment. Income requirements for this program have not been disclosed. Patients must have a medically appropriate condition/diagnosis, must be treated by a US doctor and be a US resident. |
| Who Can Apply
|
| > |
Doctor or Doctor's office must call. |
|
Required
|
| > |
Patient must inform the doctor that he/she is in need. The doctor must determine if the patient is really in need. |
|
Supply
|
| > |
Not specified |
|
Ship To
|
| > |
Not specified |
|
Note
|
| > |
Resources for HEALTHCARE PROFESSIONAL ONLY. |
| |
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.
|
| Dermagraft dermal substitute |
| |
| |
|
|
| |
Organogenesis Patient Assistance Program
|
85 Dan Road
Canton, MA 02021
Phone
:
(888)432-5232
Fax:
866-212-2888
|
|
Eligibility
|
| > |
This program provides brand name medications at no or low cost to patients that are uninsured. Income requirements for this program have not been disclosed. Patients must be a US resident. |
| Who Can Apply
|
| > |
Doctors or the doctor's office must call to have an application faxed or mailed. |
|
Required
|
| > |
Doctors must complete a section and sign. Patients must complete a section of the application, sign and attach proof of income. |
|
Supply
|
| > |
Not specified |
|
Ship To
|
| > |
Doctor's office |
|
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.
|
| Dermagraft dermal substitute |
| |
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.
|
| Dermagraft dermal substitute |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
|
|