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CORE Patient Assistance Program
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PO Box 7588
Overland Park, KS 66207
Phone
:
888-587-3263
Fax:
866-676-4073
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Eligibility
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Patients must have no prescription coverage for the needed medication, be at or below 500% of the Federal Poverty Level, have a medically appropriate diagnosis/condition and be a citizen or legal resident. |
| Who Can Apply
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Patients or healthcare providers can call to have an application faxed or mailed. It can also be downloaded. |
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Required
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Doctors must complete a section and sign. Patients must complete a section, sign, attach a copy of proof of income, and attach front and back copy of insurance card. |
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Supply
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Not specified |
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Ship To
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Doctor's office |
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Note
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Contact program for Spanish application. |
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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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| Bendeka |
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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 |
(Requires Acrobat Reader) 
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Patient Access Network Foundation (PAN)
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PO Box 221858
Charlotte, NC 28222
Phone
:
(866)316-7263
Fax:
(866)316-7263
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Eligibility
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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
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Patients or healthcare providers can complete the application online or by phone. |
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Required
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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. |
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Supply
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Not applicable |
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Ship To
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Patient sent card to be used at pharmacy |
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Note
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*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.
|
| Bendeka |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
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