| |
Diplomat's Co-Pay Assistance Navigator Program
|
Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
:
(877)977-9118
Ext 89864
Fax:
(810)282-0176
|
|
Eligibility
|
| > |
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
|
| > |
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. |
|
Required
|
| > |
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. |
|
Supply
|
| > |
Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
|
Ship To
|
| > |
Once approved medication is shipped to Patient's home within 2 business days. |
|
Note
|
| > |
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 |
| |
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.
|
| Actemra injection |
| |
| |
|
|
| |
Genentech Access to Care Foundation (Actemra, Rituxan)
|
1 DNA Way
Mail Stop 857A
South San Francisco, CA 94080
Phone
:
(866)681-3329
Fax:
(866)681-3329
|
|
Eligibility
|
| > |
This is program is intended for patients with no prescription coverage or have been denied coverage. Medicare PartD determined case by case. Gross annual household income at or below $100,000. Must be treated by US licensed healthcare provider. |
| Who Can Apply
|
| > |
Doctor/Doctor's office starts process by filling out enrollment/statement of medical necessity forms. Application received via fax, mail or download from website. Return application via fax or mail. |
|
Required
|
| > |
Diagnosis/Medical Criteria not disclosed. Doctor must complete and sign statement of medical necessity. |
|
Supply
|
| > |
Amount/Supply varies. Refill process and limit not specified. New application must be completed yearly. Patient must complete Patient Authorization and Notice of Information Form available on website, attach proof of income. |
|
Ship To
|
| > |
Ship to Doctor's office, hospital, or pharmacy. |
|
Note
|
| > |
Rituxan RA: Rheumatoid Arthritis
Rituxan MPA: Microscopic Polyangilitis
Rituxan GPA: Granulomatosis with Polyangilits (Formerly known as Wegener’s Granulomatosis) |
| |
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.
|
| Actemra injection |
| |
| |
|
|