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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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| Aubagio tablet |
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MS One to One Patient Assistance Program
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One to One Support Services
PO Box 220790
Charlotte, NC 28222
Phone
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(855)676-6326
Fax:
(855)557-2478
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Eligibility
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Must be uninsured or rendered uninsured. Medicare PartD patients not eligible. Income must be at or below 500% of FPL. Must be US citizen or legal entrant. |
| Who Can Apply
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Call for application to be faxed or download from website. Application must be faxed back to company from Doctor's office. |
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Required
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Medically appropriate condition/diagnosis required. Doctor must complete section and sign. Patient must complete section, sign application and consent. Patient will be notified of decision. |
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Supply
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Amount/supply not specified. Refills are automatically sent out. Refill limit of 1 year. Company contacts patient about reapplying. |
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Ship To
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Ship to Patient's home. |
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Note
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Patient must have a US prescriber. |
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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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| Aubagio tablet |
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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 MS One to One Patient Assistance Program |
(Requires Acrobat Reader) 
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