| |
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.
|
| Veltassa |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
(Requires Acrobat Reader) 
|
| |
|
|
| |
VeltassaKonnect
|
PO Box 43848
Louisville, KY 40253
Phone
:
844-870-7597
Fax:
888-623-7092
|
|
Eligibility
|
| > |
Patients must be uninsured or underinsured. Medicare Part D recipients are not eligible for this program. Income requirements and diagnosis criteria for this program have not been disclosed. Patients must reside in the US, DC, Puerto Rico or the US Virgin Islands. |
| Who Can Apply
|
| > |
Patients or healthcare providers can download an application. |
|
Required
|
| > |
Doctors must complete a section, sign, and attach required documents. Patients must complete a section, sign, and attach required documents. |
|
Supply
|
| > |
Varies |
|
Ship To
|
| > |
Patient's home |
|
Note
|
| > |
*The patient receives a free 10-day supply of VELTASSA directly—even before coverage is determined. If the benefit verification process takes longer than expected, a second 10-day supply of VELTASSA will be shipped to your patient at no cost. |
| |
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.
|
| Veltassa |
| |
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
|
| Download printable Form |
| (Requires Acrobat Reader)
|
| |
|
|