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Patient Assistance Information

 
3 Programs for Erbitux
 
 
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.
 
Erbitux
 
 
 
Good Days Program

6900 dallas Parkway
Suite 200
Plano, TX 75024
Phone : (877)968-7233
Fax: (214)570-3621
Eligibility
> Insurance requirements not specified, this includes Medicare PartD. Income requirements for this program have not been disclosed. US residency requirements not specified.
Who Can Apply
> Call to have application faxed, mailed, download from website or apply online. Return application via fax, mail or submit online. Patient and/or Doctor are notified of decision.
Required
> Diagnosis/Medical Criteria not specified. Doctor gives prescription to patient. Patient must complete application, sign and attach required documents.
Supply
> Refill process and limit not specified. Must re-enroll at the end of every calendar year.
Ship To
> Shipping location not specified.
Note
> 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.
 
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.
 
Erbitux
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form Good Days Program
(Requires Acrobat Reader
 
 
PatientOne Oncology

PO Box 4280
Gaithersburg, MD 20885
Phone : (866)472-8663 Ext opt 2
Fax: (877)366-0585
Eligibility
> 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
> 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.
Required
> Must be used for on-label diagnosis
Supply
> 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.
Ship To
> Medication will be shipped to Doctor's office.
Note
> 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.
 
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.
 
Erbitux
 
Printable Application Forms
Applications that patients can fill out and bring to their doctor.
 
Download printable Form PatientOne Oncology
(Requires Acrobat Reader