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Diplomat's Co-Pay Assistance Navigator Program
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Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
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(877)977-9118
Ext 89864
Fax:
(810)282-0176
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Eligibility
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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
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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. |
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Required
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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. |
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Supply
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Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
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Ship To
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Once approved medication is shipped to Patient's home within 2 business days. |
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Note
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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 |
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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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| Alimta injection |
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PatientOne Oncology
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PO Box 4280
Gaithersburg, MD 20885
Phone
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(866)472-8663
Ext opt 2
Fax:
(877)366-0585
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Eligibility
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This program is intended for patients that are uninsured or are underinsured for needed medication. Medicare part D eligibility not specified. Income must be at or below 500% of FPL. Must be US resident. |
| Who Can Apply
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Call for application to be faxed or download from website. Doctor must complete application and sign. Patient must complete application, sign, and attach copy of income. Healthcare Provider will be notified via fax of decision. |
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Required
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Must be used for on-label diagnosis |
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Supply
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Amount/supply varies. Doctor/Doctor's office must complete replacement form for refills. Refill limit is not specified. New application must be completed every 12 months. |
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Ship To
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Medication will be shipped to Doctor's office. |
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Note
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The patient and physician must submit information to PatientOne for a benefits investigation before application will be given for the assistance program. For underinsured patients program helps connect patients with programs that can help them cover the cost of copayments and deductibles. Patients who do not have prescription insurance are reviewed for eligibility into the PatientOne patient Lilly assistance program.
Certification of Brand Name Drug Usage Form only needs to be completed for those seeking assistance for Gemzar. |
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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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| Alimta injection |
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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 PatientOne Oncology |
(Requires Acrobat Reader) 
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