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Patient Assistance Information

 
2 Programs for Beleodaq
 
 
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.
 
Beleodaq
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form
(Requires Acrobat Reader
 
 
Spectrum Therapy Access Resources (STAR) Program

PO Box 220551
PO Box 220684
Charlotte, NC 28222
Phone : (888)537-8277
Fax:
Eligibility
> Patients must be uninsured or underinsured, meet income requirements that have not been disclosed and be a US citizen or permanent resident. The medication must be used for outpatient use only.
Who Can Apply
> Patients or healthcare providers can call to have an application faxed or mailed. It can also be downloaded.
Required
> Doctors must complete a section and sign. Patients must complete a section, sign and attach insurance information.
Supply
> Varies
Ship To
> Doctor's office
Note
> Insurance benefits, claims assistance,/or other reimbursement help is offered.
 
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.
 
Beleodaq
 
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
(Requires Acrobat Reader